Diagnosis of Personality Disorders A Trauma Informed Approach

So welcome to everybody. Today's presentation on differential diagnosis of personality disorders from a trauma informed perspective. I'm your host, Dr. Donnellice Snipes. In this presentation, we're going to review the criteria for the various personality disorders and identify some common errors in diagnosis. Let's just start out with what is a personality disorder? In general, when we talk about personality disorders, they seem to have a lot of symptoms that overlap with a lot of other disorders. And the answer is yes, they do. So what is a personality disorder? It is an enduring pattern of inner experience and behavior that deviates markedly from cultural expectations in two or more areas. So there are a lot of things here that we need to look at. Enduring pattern. So this isn't just something that happens after a trauma. This isn't something that just happens during a certain period of time. Inner experience, how the person is feeling about themselves in the world, and behavior that deviates markedly from cold cultural expectations. And we need to examine what that might be, what that might look like for each individual and consider not only, you know, race and ethnicity and gender and gender identity, but also other cultures such as age and the time that people grew up in. But it needs to. To differ markedly from cultural expectations in two or more cognition, affectivity. So the range of affect, whether the person is flat or emotionally dysregulated, the intensity, lability, and appropriateness of the affect. So we want to look at, for that person's culture, for that person's environment, for their context. Is their affect culturally appropriate? Their interpersonal functioning, is it culturally and contextually appropriate? And impulse control, is it culturally and contextually appropriate? Now, one of the other features of personality disorders, as opposed to maybe mood disorders, the behavior is inflexible and pervasive. So it's not just present in one area. There are. There's a lot of talk on different social media platforms about narcissism, for example. And if the person displays what we will call narcissistic traits at work, but not at home, not with their friends, then they don't have narcissistic personality disorder. The behavior is inflexible and it's pervasive into most areas of their life. You're not going to see it just in one area. And that is another key feature in differentiating it. Behavior is stable back to adolescence or early adulthood. Sometimes we'll start seeing the behavior in childhood, but we do need to see it no later than, you know, late teens, early 20s, in order to qualify for a diagnosis of a personality disorder. The personality disorder diagnosis is not better explained by another mental disorder, medical condition or substance use. And we're going to talk about these kind of ad nauseam as we go through the presentation today, because in my opinion, and this is, I told you I was passionate about this complex ptsd, CPTSD is not a diagnosis right now. It's just not. And there's not a whole lot we can do to change that. But when we look at the history of a lot of the people who display inflexible, pervasive behaviors, many times these are behaviors that were learned in childhood and seem to be methods that they developed as a means of surviving chronic or extensive trauma. So we, I feel that we really need to look at kind of what's going on. Is it better explained by trauma? Is it better explained by schizophrenia? Is it better explained by head trauma, for example, or the effects of substance use? To be diagnosed in someone under 18 years, symptoms must have been present for at least one year. So if you're diagnosing a personality disorder in a 16 year old, the symptoms must have been present for at least a year. However, if you're diagnosing antisocial personality disorder, can't do it before age 18. And that's just one of those little gotchas in the DSM 5tr. However, with antisocial personality disorder, generally prior to age 18, you're going to see conduct disorder. Paranoid personality is first apparent in childhood with solitariness, poor peer relationships and social anxiety. There's underachievement in school and the person seems to be hypersensitive. The child seems to be hypersensitive. These characteristics need to be present before any psychotic symptoms emerge. And that's one of the ways that you differentiate it from the schizophrenia and spectrum disorders or depression with psychotic features that the poor peer relationships, the social anxiety and the paranoid ideation is not concurrent with other psychotic symptoms, including hallucinations or delusions. What are the characteristics? And each personality disorder has a different mnemonic. I didn't come up with most of these. You can find them online. But I like mnemonics, especially for those of you who are getting ready to take your NCE or your NCMHCE because it makes it easier to remember. Am I checking all the blocks? So for paranoid personality, the person is suspect. Makes sense. People who have paranoid personality disorder are often suspicious. There's a pervasive pattern of distrust and suspiciousness. So suspect they suspect of infidelity or disloyalty. So they are concerned that people are not going to be Honest and faithful. They are unforgiving and begrudging. Now I want you to think as I go through these, how might this develop in response to chronic trauma, adverse childhood experiences or intergenerational trauma so suspect of infidelity or disloyalty, Unforgiving and begrudging. You know, it's hard to let go of that anger. They don't know how, they don't feel safe. Suspicious of others motives, perceives and quickly reacts to attacks that may not be apparent to others. So they may be more hyper vigilant to non verbals. They may be more hyper vigilant to perceived attacks. They perceive people in dichotomous terms, enemy or friend. There's no middle ground. You're either with me or you're against me. Confiding in others is feared and threats perceived in benign events or remarks. So people may say something that is not meant to be attacking, but the person perceives it as attacking. If you grew up in an environment in which your caregivers were distrustful of other people, in which your friends were distrustful of other people, it might make sense that that schema would form that other people are not trustworthy. So the person may become suspicious of others motives and suspect infidelity or disloyalty growing up in that kind of environment. Now remember, these characteristics can present in childhood, but definitely by adolescence and early adulthood. So something happens back here. And a lot of times people who display characteristics of personality disorders grew up in environments where there was a lot of trauma, there was a lot of stress, and there was a lot of anger and anxiety that people just didn't know what to do with. The child did not develop the tools to deal with this and or the child was betrayed enough times that they became very unforgiving. They're like fool me once, shame on. However that saying goes, they learned from interacting with others in their environment that it was not safe. So they put up this wall that is unforgiving and begrudging. Can a person who has experienced adverse childhood experiences or complex trauma or even straight up PTSD develop personality disordered characteristics? Well, yes. One of my concerns, and again I said I'm passionate, is that when clinicians hear the term personality disorder, a lot of times it puts them on high alert because personality disorders have been so stigmatized. So we want to change the dialogue from why are you doing this? To what happened to you? What happened that prompted the development of these survival skills? Schizoid personality. And the mnemonic here is distant people who are schizoid tend to be somewhat distant. And again, four plus criteria. You'll find that in personality disorders it's either four or five criteria in order to meet the diagnostic threshold, if you will. But again, if somebody meets three criteria and they're supposed to have four, does that mean we don't treat them? Of course not. However, in terms of testing and making official diagnoses, it is important to know how many criteria you need. Distant stands for detached or flattened affect. They seem to lack emotion and may react passively to adverse circumstances. We have talked in other videos, if you've watched my other videos on the neurological impact of trauma, that when someone is experiencing or has been exposed to chronic trauma, chronic stress, their HPA axis, their stress response system, becomes disregulated itself. It turns down the sensitivity. So what used to cause them to get excited or to get angry or to get anxious? It's just like their body says, you know what? I ain't got it in me to stay this revved up and get all excited or stressed out this often. I just, I don't have it in me. So the person presents much flatter than their peers, for example. And the best analogy I can make, if you remember Winnie the Pooh, Eeyore often displayed flattened affect. Nothing really got him upset, nothing really got him angry. He just kind of went along. And they react passively to adverse circumstances. Well, if you have been chronically exposed to adverse circumstances, guess what? You may have a sense of helplessness and hopelessness in the face of adversity. And figure, what's the point? What's the point in trying? The person who has schizoid personalities, indifferent to criticism or praise, they've built that wall up. So you can't hurt me, but you also can't love me. I'm keeping other people out because they're not safe. Safe sex is of little interest when you're chronically stressed. When your HPA axis has become dysregulated, not only does it affect your mood, it affects your libido, it affects your gonadal hormones. It doesn't surprise me that people who've been exposed to trauma would find little interest in sex because they they are. Their brain is still in the survival mode, not in the hey, let's reproduce mode. You know, it's not safe to bring an infant into the world when you feel like you're helpless, hopeless, disempowered tasks are done solitarily. Makes sense. If people stress you out, you probably want to stay alone. There's an absence of close friends, neither desires nor enjoys close relationships. Well, if you've done something, maybe you love ice cream, but you're lactose intolerant and you eat ice cream once and oh boy, it upsets your tummy, but you really desire ice cream, you really love ice cream, so you do it again and oh boy, it upsets your stomach. Eventually, after enough iterations of that, a part of you is going to say, you know what? I don't want ice cream anymore. It always ends up causing me pain. This may be a situation with people who are schizoid and takes pleasure in few activities. When you're detached, when you've got flattened affect, not only does it mean that you may not trigger that stress response as robustly, but you're also not triggering the excitatory excitation response as robustly. So it would make sense that there may be alterations in the endogenous opioids and dopamine. Do all people with schizoid personality have a trauma history? No, we can't say all people with X will develop any particular diagnosis. But it is certainly important from a trauma informed perspective to ask ourselves, how do these behaviors make sense? What happened that triggered or prompted the development of this? And it could be that there are some neurological differences. The person could be neuroatypical. However, we want to get back to understand what's going on with this person and what is prompting these responses. Differential diagnosis Paranoid personality. If the person is avoiding others, are they avoiding them because they fear others are going to hurt them? Or are they avoiding them because they just have no use for other people? At this point, addiction, especially depressants and opioids, can present or can cause a person to present with flattened affect. When people are engaged in their addiction, many times they will isolate if they feel like other people are going to criticize them or try to make them go into recovery. Persistent depressive disorder. If somebody has ongoing depression, what we used to call dysthymia, we do want to recognize are these behaviors and we'll go back here. Detached flattened affect. You're going to see that in depressive disorders. Sex of little interest. Often see that in depressive disorders. Absence of close friends. You may see that in people who have depressive disorders because they don't have the energy, they're exhausted, they don't have the energy to engage and takes pleasure in few activities. One of the key features of depression is anhedonia, Inability to feel pleasure in things that used to give people pleasure. So we do want to rule that out rule out any psychotic disorders if there are concurrent hallucinations, delusions. It's important to examine whether it's schizoid personality or whether we're talking about a schizophrenia spectrum disorder and autism spectrum disorders. People who are on the autism spectrum going back may exhibit behaviors that seem to make them appear distant. They want to answer, engage in tasks solitarily. They may have an absence of close friends, detached or flattened affect, indifferent to criticism or praise. There are a lot of characteristics here. So we need to rule out autism spectrum disorders by looking at does this person have the additional criteria, meet the additional criteria for autism spectrum? People with autism spectrum are often survivors of complex trauma because due to being neuroatypical, things that they experienced in infancy and toddlerhood may have caused them to perceive the world as very painful and dangerous because their caregivers didn't understand that they had those neurological differences. So they may have developed some of these compensatory behaviors to survive what felt like a very traumatic environment. Schizotypal, you have to have five characteristics. And I forgot to put the mnemonic up at the top here. It is me peculiar. Magical thinking is characteristic in schizotypal behavior. The person, well, magical thinking, you understand that experiences unusual perceptions. Sights, sounds, smells. They may experience things that aren't there or experience them vastly differently. Paranoid ideation. Eccentric behavior or odd appearance. Constricted or inappropriate affect. Unusual thinking or speech. Lacks close friends. They may have ideas of reference. If something happens, then that means this and anxiety in social situations. You want to rule out psychotic and developmental disorders. Children have magical thinking. When my son was little, he used to believe in poof up powers. You know, he thought he could wish for something and it would poof magically appear. And I had to break it to him that that wasn't going to happen. Many people may have unusual perceptions. We want to certainly differentiate that from schizotypal personality disorder. Remembering that for an 18 year old or a 20 year old to have magical thinking that may be different. You also want to rule out the effects of substances, for example lsd. People who have used LSD may have ongoing perceptual disturbances. So they may experience unusual perceptions, maybe even paranoid ideation. They often will not meet all five criteria. Avoidant personality disorder. This person is characterized by the mnemonic cringes. They cringe when they think about having to be around people. Interestingly, in the DSM 5tr in the differential diagnosis section, they were very vague about how do you differentiate avoidant personality from social anxiety. And the best they could give was in social anxiety. Theoretically, the person does not have low self esteem, which I might argue with. So there is a lot of discussion about whether avoidant personality disorder represents a subtype of social anxiety. However, avoidant cringes stands for certainty of being liked before getting involved. So this person is not going to take a lot of risks. Rejection preoccupies their thoughts. Intimacy is restrained due to fear of getting shamed. New relationships are inhibited. So even if they get into a relationship and start to get involved, they're often going to be very withdrawn. They're going to keep that wall up for quite a while because it may be very, very threatening. Gets around occupational activities involving others, so they like to work independently. Embarrassment prevents new activity. Self is viewed as unappealing or inferior. Again, and I know I may be belaboring this point, but I want you to look at these behaviors and think, if somebody grew up in a emotionally abusive, physically abusive environment or exposed to chronic trauma and stress, do some of these make sense? Certainty of being liked before getting involved? Well, if they have abandonment anxiety, if they've been abandoned by their caregivers, if they've been abandoned by their friends, then yeah, it makes sense that they don't want to try to open their heart and just get it stomped on. Rejection preoccupies their thoughts. Let's look back. Who rejected them in the past, if it was, especially if it was their caregivers. And then, you know, it kind of makes sense that they may expect others to reject them. The people that gave me life didn't even like me, so why should I expect anybody else to like me? And that abandonment anxiety is just overwhelming. Intimacy is restrained, dear to fear of getting shamed. Remember, intimacy is not just sex. Intimacy is not just physical. Intimacy is also emotional and cognitive. So the person is going to restrain sharing their feelings, sharing their thoughts, and sharing their physical self due to fear of being shamed, being rejected. So we want to ask what caused that? Where did the person get the idea that it was more than likely that if they shared their thoughts, feelings or ideas, they were going to get ridiculed or shamed or rejected, which you can understand going, trying to make a new relationship. If you're already that self conscious and that terrified of abandonment, Getting into a new relationship would be terrifying. So they may not try to get into a lot of new relationships. And when they do, they take it ultra, ultra, ultra slow. Embarrassment prevents new activity that also goes back up, kind of paralleling with intimacy. People who are avoidant often will not try new activities where there's a risk of them being judged or ridiculed or failing. And sometimes they won't even do it in their own home. Maybe they want to learn how to paint so they order all the Bob Ross videos. And I love Bob Ross us, but they are, they don't actually get started because they're afraid that if they, they try they won't be quote good enough and then they'll reject themselves. You do want to rule out body dysmorphic disorder, eating disorders and social anxiety. When you're diagnosing avoidant personality disorder, it is worthy of note again that in my clinical experience, 20 some odd years and personal opinion, however long I've had the opinion, social anxiety tends to carry with it much less stigma than avoidant personality. So before you start slapping a personality disorder diagnosis on somebody, let's make sure we've ruled out the other things. You're not going to have social anxiety, concurrent or comorbid with avoidant personality. You got to choose one or the other dependent personality. The mnemonic here is reliance. Makes sense this one. You need five characteristics. Reassurance is required for decisions. Expressing disagreement is difficult, often due to fear of rejection or punishment. Life responsibilities are assumed by others. Initiating projects is difficult, often due to low self confidence, low motivation. They feel helpless and uncomfortable when they're alone. They go to excessive lengths to obtain nurturance. They seek companionship or another relationship urgently when a close relationship ends. And they have exaggerated fears of being left to care for themselves. In people with dependent personality disorder, it is not uncommon that they came from a highly enmeshed family in which the caregivers were very demanding and very controlling and everything. Not everything, that's an extreme word. Many times when the child tried to make a decision or do something, they were told they were wrong and they were rejected. And they were told that if they wanted acceptance they needed to fall in line. So there was a lot of enmeshed controlling behavior from the caregivers. This is not completely unheard of in families where there is one or more people with an addiction because the mantra in the addicted family is don't talk, don't trust, don't feel. So it is not uncommon for people who grow up in addicted families to be to have some dependent characteristics and or codependent characteristics. But again we want to look at what's going on and each one of these things that we use to as a criteria for the different disorders is often a ready made treatment target. If You've got somebody who is who you're seeing, and they exhibit dependent personality disorder characteristics. Maybe they have difficulty initiating projects. So exploring why that is, you know, what makes it difficult, what projects might you want to initiate if you had the energy, if you had the motivation, if you had the confidence, and then helping them set goals and start to accomplish those things to build up their sense of. Of personal power, efficacy, and competence? Now we jump down into cluster B, and I know I did them out of order. I did a C. Now, B, Cluster B is what most people are familiar with, and that's your antisocial, your borderline, your histrionic. Antisocial personality disorder is characterized by corruption. Conformity to the law is lacking. Obligations are ignored, reckless disregard for the safety of self or others. Remorse is lacking. They're underhanded. They may be deceitful, lying, conniving, planning is insufficient. They tend to be impulsive, and they tend to have a temperature. For antisocial personality disorder, they must have symptoms of conduct disorder before age 15. And we need to differentially diagnose it from addictive disorders and mania or hypomania. So let's go back up and look at this. And I know it's a little bit of difference than you may have heard from others, but in people who grew up in environments where they. The culture that they grew up in there was lacking in conformity to the law, and this is not uncommon. I worked in probation and parole for several years when I was right out of college. And there were a lot of the people I worked with, not all by any means. There were a lot of people that I worked with that had been in and out of jail or prison all their life, and their family had been in and out of jail or prison all their life. So they had developed a criminogenic mentality. And the culture of jail, the prison culture is very different than the culture outside of jail. However, they'd spent so much time in institutions that they had become acculturated to the institution. We want to look at that, we want to ask ourselves, are people acting this way, whatever this way is because of trauma? Are they acting this way because they don't have other skills, they don't know how to react differently, they don't have experience in successfully navigating things. And that's really important to consider. So conformity to the law is lacking. If you grew up in an environment where it was, you know, everybody was selling weed under the table and whatever else, okay, obligations are ignored. Many times when people Are stressed, depressed, feeling helpless, hopeless, oppressed. They may get to that point where that HPA axis is dysregulated and they're just like, whatever, I don't care. I don't have the energy to pay attention to these obligations that bring me absolutely no pleasure. No dopamine, no endorphins, no go. Reckless disregard for the safety of self or others can also be thought of in terms of doing things in order to help themselves feel empowered or to feel a rush. A lot of times we see impulsivity in people with antisocial personality as well as people with long standing trauma or sometimes even depression. They engage in behaviors so they can get that dopamine rush. Remorse is lacking. And this is also absence of empathy in some of these cases. Maybe they never had empathy. Okay, that's possible. It's also possible that they did have empathy and they did care for things and those things were taken away or were destroyed or people harmed them. And so they quit having empathy for others because, well, you're gonna hurt me. You have no empathy for me, so screw you. Basically, sorry. Underhanding, underhanded behavior, being deceitful, lying, conning makes sense if you grow up in a culture in which that is common and irritability and aggressiveness is also also makes sense. Borderline and suicide, another five characteristic abandonment, mood instability, suicidal or self mutilating behavior, unstable and intense relationships, Impulsivity in two potentially self destructive areas, control of anger is difficult, identity disturbance, dissociative or paranoid symptoms that are transient and stress related and emptiness that feels they chronically feel empty. A lot of people and the best example that or metaphor that I can come up with for borderline is walking on a tightrope. People with borderline personality symptoms often feel like they are walking on a tightrope. Teetering between safety and danger. There is no middle ground. They're either safe or they're falling and they're in danger and they're in peril. So abandonment is very common and a lot of people, obviously I can't say all, but a lot of people with BPD have a history of abandonment starting in early childhood. Whether it was emotional abandonment or physical abandonment doesn't really matter. The child felt unsafe and insecure. The mood instability often if people don't have a secure primary attachment, they don't develop emotional intelligence. If they grow up in an environment that is chaotic or trauma filled with, then they may have that dysregulation of their HPA axis which leads to what I call flat to furious we talked earlier about when that HPA axis is dysregulated. A lot of times people just kind of feel flat. Their sensitivity to input is turned down because they just don't have it in them anymore. But when that stress response is triggered, it triggers a tsunami of stress chemicals. So they go from flat to furious just like that. Suicidal or self mutilating behavior is another one of those things we want to look at. When you're living constantly on the borderline, constantly teetering, constantly fearing abandonment, constantly feeling like you are not in control of your emotions, it can feel exhausting. And suicidality is not uncommon in people with borderline personality characteristics. Non suicidal self injury is also not uncommon in people with borderline personality characteristics. And non suicidal self injury is behavior that is geared to help somebody cope. They don't want to die, they want to somehow try to cope with the pain. And the self mutilating behavior can serve to either help them feel something, it can help them distract their attention from the chaos in their head and in their heart to something they can control, which is physical pain. And for some people, the endorphins that are released when they do engage in self injurious behavior may help temporarily medicate the emotional agony. There are a lot of reasons that we see non suicidal self injury. It's important to recognize that even if the person says, you know, this is non suicidal self injury, I don't want to die, doesn't mean they can't make a mistake. So we need to take it seriously. Regardless of whether it is not overtly suicidal, unstable and intense relationships. We're back on that tightrope. They are feeling very intense. If you're on a tightrope, you're going to, I mean, I'm going to have every muscle in my body clenched because I don't want to fall. And a lot of times that's how people who have borderline characteristics feel. Impulsivity in two potentially self destructive areas. When people feel out of control, they may react impulsively. This can include extreme anger outbursts. A lot of times people who are borderline don't have a good sense of self. They are somebody else's daughter, they are somebody else's friend, they are somebody else's worker. They get their worth from being something to someone else. They don't know. They can't identify a personal worth. The dissociative symptoms can be transient and self stress related, which we do want to remember. Dissociative symptoms are not uncommon and paranoid symptoms are not uncommon in people Who've experienced a history of trauma and this can be one strategy that they developed in order to survive until now, and emptiness or chronic feelings of emptiness. If you don't know who you are, if you don't feel like you're lovable for who you are, you rely on others to tell you you're okay. There's a sense of, you know, not being able to love yourself, to differentially diagnose. We want to rule out addictive disorders. A lot of times that most of my career I've worked in co occurring disorders. And as people's neurological health returns, as their physical health returns, as they deal with their traumas and, and their guilt and everything else that happened during the addiction, a lot of times these symptoms become much less prominent. Therefore, we want to look at the function of the symptoms for the person with the addiction. We want to rule out depression, generalized anxiety, intermittent explosive disorder, bipolar, paranoid personality, antisocial and dependent. Common co occurring depression is very common with borderline personality disorders, as are eating disorders and PTSD. The prevalence of borderline personality may be 6% in primary care, 10% in mental health settings and 20% in inpatient hospitals. So there is a high proportion of people that end up presenting in mental health settings and in psych hospitals with borderline personality characteristics. Nearly 50% of people with a BPD diagnosis in early adulthood don't meet criteria 10 years later. Unfortunately, they still have that diagnosis following them around everywhere. I thought that was a really interesting statistic. Many adolescents and young adults display borderline characteristics as they develop identity, adjust to independence and resolve their existential conflicts. Which is another reason why they say if it's going to be diagnosed in childhood, it needs to have persisted. All of the criteria need to have persisted for at least a year because we want to make sure that what we're looking at histrionic Praise me five characteristics. The person exhibits provocative or sexually seductive behavior. Relationships are considered more intimate than they are. They're uncomfortable when they're not the center of attention. They're influenced in easily by others. If somebody says you need a Prada purse, then they've got to have a Prada purse. Their style of speech is impressionistic and lacks detail. Their emotions are often rapidly shifting and shallow. Very chameleon like what fits the situation. They are often made up physically in order to draw attention to self. And their emotions can be exaggerated or theatrical. Think dramatic. Think about how these behaviors might have helped somebody. In a household in which caregivers were completely detached, they were overwhelmed with their addictions. Their mental health issues, domestic violence, whatever, and why a person, why a child might develop these types of behaviors. In order to get approval from somewhere, in order to get acceptance from somewhere. Think about what are their attachments like, what was their primary secure attachment like? And if it was dysfunctional, how might that have caused the development of these behaviors? We do want to differentially diagnose from fetal alcohol spectrum disorder, and I'm going to talk about that in a minute. Manic or hypomanic conditions, and when somebody is in a manic episode, they may display most or all of these criteria. The difference is with the personality disorder. Personality disorders are pervasive, ongoing. The manic or hypomanic is episodic. So you may see these behaviors, then they go away for a while, and then they may come back for a while. And we differentially diagnose from dependent personality because the person who's histrionic does not have difficulty making decisions. They don't excessively rely on others. They need to be the center of attention. Narcissistic, special is the mnemonic here. They believe they're special or unique. They're preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. They have a sense of entitlement. They can be conceited, they engage in interpersonal exploitation. They can be arrogant, and they often lack empathy. Remember, in order to qualify for a narcissistic personality disorder, somebody only has to have five of these qualities. Not every person with NPD lacks empathy, for example. And that's a really important thing that we need to take into consideration. Believing they're special or unique, preoccupied with fantasies of unlimited success and power. And they are. They often use people as a means to an end. And they feel that grandiose sense of self importance. You should be, you know, praising me. You should be listening to me. My way is the right way, my way or the highway. And they often don't care if they hurt your feelings. Now, whether they're in unable to express empathy or unwilling, we need to explore. And again, unwilling may come from a history of trauma and just kind of shutting that down. And it's also important to differentiate narcissistic behaviors from high self esteem that may be somewhat socially aggressive, for example, in one situation in a workplace versus a personality disorder where these behaviors are going to exist in multiple different contexts and they're pervasive from the time the person is a teenager through their life. You want to differentially diagnose with psychotic disorders including delusions of grandeur, antisocial Personality disorder and antisocial. You have the disregarding the law. And again manic or hypomanic episodes. An obsessive compulsive disorder. And I know I'm running low on time so I'm going to speed through these loses the point of an activity due to preoccupation with detail. Now obsessive compulsive disorder is very very different than obsessive compulsive personality disorder. So we need to separate those. Obsessive compulsive personality disorder. The person is very concerned, very rigidly attached to rules and regulations. Preoccupation with detail. Their ability to complete tasks is compromised by perfectionism. Worthless objects can't be discarded. They need to hold on to everything. Friendships and leisure activities are often excluded due to a preoccupation with work. They need to get this thing done right so that all that feel good stuff they don't have time for. They may be inflexible, scrupulous or over conscientious on ethics, values or morality not accounted for by religion or culture. They are reluctant to delegate unless others submit to their exact guidelines. The micromanagers of the world. They are often miserly toward themselves as well as others and stubborn and rigid in their the way they go about life. This is the way we've always done it. This is the way we're going to continue to do it. And there's no room for modification. Differential diagnosis with Autism spectrum Disorder, Social Anxiety, Schizoid Personality, Obsessive compulsive disorder and hoarding disorder. Suicidal ideation tends to be higher in people with personality disorders. Go figure. They have behaviors that they exhibit that are markedly different from cultural norms. Which means basically they're not fitting in very well. Which means they're probably going to experience a lot more conflict, a lot more sense of disempowerment in certain situations and may experience a greater sense of hopelessness. So yeah, it makes sense. Issue number one that we need to pay attention to is acculturation. Do not confuse with problems or personality disorders with acculturation. Are these behaviors normal or normative in the person's particular culture or cultures? And I use the example of jail and prison before because that does have a much a very pronounced culture that goes with it. Consider the influence of intergenerational pts. And no, I did not put the D on there for a reason. Post traumatic stress that is transmitted from generation to generation. So if grandma experienced a trauma and her the way she perceives the world was altered because of that trauma. Makes sense. Grandma May teach that to mom. Mom may develop those schema because grandma told, told mom the world is not a safe place. You need to be on your guard. And so mom may teach that to junior. Now, are we saying those people are paranoid because they perceive things as dangerous that we don't perceive as dangerous? Well, heck no. You know, there's a reason shared beliefs, values, customs, behaviors, traditions, institutions, arts, folklore, and lifestyle. This kind of goes along with culture. We need to explore whether it is normative based on a person's culture. Minority groups, immigrants, individuals from different ethnic backgrounds and people with disabilities may display suspiciousness, guarded or defensive behaviors resulting from perceived neglect or indifference by the majority society. And I say perceived not because they didn't experience it, because, but because they experienced it and they felt it, they perceived it. Some ethnic groups also display culturally related behaviors which should not be confused with paranoia, avoidance or dependence. Some cultures are very different in what is considered appropriate for children to do and how they interact with their parents or how couples interact. So we do want to make sure that we're paying attention to that. Don't misdiagnose. Based on stereotypical gender roles. People who are biologically female are more often diagnosed as borderline histrionic or dependent. And people who are born biologically male are often diagnosed more often as antisocial or narcissists, narcissistic. So we want to look at in the culture this person grew up in, what aspects of their behavior can be attributed to cultural gender roles and is this markedly different from what's expected? Personality traits are only personality disorders when inflexible, maladaptive, persistent, and cause functional impairment or subjective distress. If the person behaves in a way that you don't like, but it's not causing them any problem, you know, they're getting along very well in life. Thank you very much. Then is it a personality disorder? We want to differentiate personality disorders from mood disorders with psychotic features. Paranoid, schizoid and schizotypal must not have occurred exclusively within schizophrenia, bipolar disorder, or depressive disorders with psychotic features. We need to make sure that we're well, effectively differentially diagnosing personality changes that can happen as a result of trauma may include a lack of interest in social relationships or avoidance, solitariness, not wanting to be around others, wanting to do things, work by themselves, affect, flattening and emotional numbing, irritability, pessimism, lack of trust, or what some might think is paranoid hypervigilance, a need for control in situations, we've got to do it this way because if we do it this way I'm safe. If we don't do it this way, I'm not safe and avoidance of reminders of the traumatic event. These are all all of these symptoms are represented to a greater or lesser degree in the majority of personality disorders and addictions with People with addictions spend more time getting, using or recovering from the substance than intended. When they can't get to the substance, they are often irritable or grudging, especially during withdrawal. They may be paranoid or irritable while under the influence and they may use histrionic type behaviors to manipulate getting the substance or antisocial type behaviors. They may have an inability to stop or cut down. They may have a dependence on their dealers and be willing to do whatever their dealer says as long as they can get their fix. They may have a failure to meet important role obligations because of the addiction, too much time spent getting, using or recovering, a reduction in hobbies and important activities, and continued use despite two or more problems. When people are in their addiction, they are often sensitive to perceived attacks on their character. They may have feelings of emptiness and low self esteem and have reluctance to confide in people or doubt people's loyalty to them when they're in the withdrawal phase. They also may be restless or irritable when they're not using. So restlessness and irritability can come for a lot of different reasons. Again, we want to differentiate from autism spectrum disorders. People with ASDs may have deficits in social emotional reciprocity, deficits in nonverbal communication, deficits in relationship skills and an absence of interest in peers, deficits in imaginative play, hypo or hyper reactivity to stimulation. So they may be reacting to pain or lack of sensation a lot of times, insistence on sameness, inflexible adherence to routines, kind of like in obsessive compulsive personality disorder and highly restricted fixated interests, again very common in ocpd, for example. And finally differentiate from fetal alcohol spectrum disorders which in the DSM 5 TR is still back in the back in conditions for further study and they call it neurobehavioral disorder associated with prenatal alcohol exposure everywhere else on in PubMed and who and everywhere else. It's called FASD. People with FASDs have high rates of suspension and expulsion because they have difficulty with mood and behavioral regulation. They may have differences in their social communication, being overly friendly with strangers, easily manipulated. There is a over preponderance of people in jail who have fetal alcohol spectrum issues because they were easily manipulated by bad actors. Personality disorders represent a long standing and pervasive pattern of behavior which causes impairments in psychosocial functioning. Many people with uncontrolled mood and or psychotic disorders may display symptoms resembling personality disorder. So we want to make sure that we're actually treating what we think we're treating. For a personality disorder to be diagnosed, the other conditions must be brought into remission, like addiction and or the pattern of personality disordered behavior existed before the onset of the mood or psychotic or substance use disorder. Many treatment centers have restrictions against admission of persons with personality disorders, asserting they need a higher level of care, but then they have nowhere to step down to. So we do need to be cognizant about our system and maybe consider changing the dialogue around personality disorders to help them be embraced as reactions or behavioral developments as a result of trauma or a history similar.