Don't Make These 8 Common Errors in Diagnosing of Personality Disorders

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs register@allce.com counselortoolbox Alrighty then. So now that we've had our daily dose of amusement, we will pick that back up because that is actually an hour video on the next installment of class. But for today, welcome everybody. I know personality disorders is, you know, not one of those things that we really generally talk about and it's not super exciting. However, it turns out that approximately 15% of the people in the United States qualify as having a personality disorder. So when we're looking at different diagnoses and providing that comprehensive treatment, this is something that we may want to consider looking at. Now you can argue if it's a long standing issue that that's going to be something that you have to address when you're addressing depression or anxiety or anything else. But in any event, just to make sure we get accurate diagnosis, we're going to look at some common errors because I find that personality disorder, actually borderline personality disorder, seems to be over diagnosed. When you look at the prevalence versus what I've seen show up in clinic, I think it's getting over diagnosed, but we'll just take a look. So we're briefly going to look at all of the personality disorders and identify eight common errors. I couldn't come up with 10, partly because we don't diagnose personality disorders all that much. Or when we do, we over diagnose, but it seems like it's one or the other. People either diagnose them all the time or they don't even go near it. And you know, since we're not doing the 5 axis diagnosis anymore, it's even easier to just kind of skip that because you know, you still be kind of a glaring issue if you didn't have an axis to so overviews of personality disorders just to kind of hit the highlights, it's an enduring pattern of inner experience and behavior that deviates markedly from cultural expectations. That's going to be an important point. Deviates markedly from cultural expectations in two or more cognition, affect, interpersonal functioning, or impulse control. The behavior is inflexible and pervasive and can be traced back to adolescence or early adulthood. A lot of times people think of personality disorders as having to have started way back in childhood. And really the only one that has a super early onset thing that we look for is antisocial. The rest of them, if we can trace it back to early Adolescence or early adulthood or adolescence. We're really still looking at a personality disorder and we want to make sure it's not better explained as a manifestation or consequence of another mental disorder attributable to medical conditions or substances. So we're going to be ruling out things like mania, addictive disorders, autism spectrum disorders and Fetal Alcohol Spectrum disorder. And the DSM 5 calls fetal alcohol Spectrum disorder something a little bit different. We'll get to it in a minute. But that's what they're talking about. A diagnosis in somewhat of a personality disorder in someone under 18 requires a duration of at least a year. So this pervasive pattern of inflexible behavior that's causing impairment in functioning and or distress has to have gone on for at least a year in someone under 18 and for more than a year in somebody over 18, pardon me. And a lot of times if people are struggling, they're going to present before this. So what's my point? My point is if somebody presents and they are, you know, young and they're having some of these issues, but they don't meet the duration criteria, this is something we want to look at as an ongoing sort of diagnosis. And you can, well, anyway, adopted as a, as well as biological children have similar chances of developing personality disorders which indicate the influence of environment. So this is really important. You know, going back to how I said I think borderline personality disorder tends to be over diagnosed. When we look back at the childhood history of people with borderline personality disorder, for example, they tend to have a high level of trauma and a high level of adverse childhood experiences really early on. So one of the things that I encourage you to do, and I encourage my supervisees and staff to do is when you're looking at the criteria, when you're looking at the symptoms of a personality disorder, for every symptom, ask yourself, how is this functional? Or how was this functional in the past for a person? You know, it may not still be functional and helpful, however, is an enduring pattern. They don't have anything to replace it. It was something that they learned, they developed to survive maybe when they were, you know, in their teens or even younger. And now, you know, it's causing problems because as an adult we expect them to react differently than we expect an adolescent to. So one of the things that as clinicians we can do is help provide them with developmentally appropriate tools to handle the stress that they're dealing with. So we're going to hit the issues first, then we're going to review the personality Disorders. I went back and forth about which one to do first, but this is what I settled on. So one of the first mistakes that are often made in the diagnosis of personality disorders is confusing problems with acculturation. We need to take into account the individual's cultural background, and maybe they haven't acculturated to our. Our culture. And this can be, they were moving from really rural to really urban. Maybe they are moving from somewhere where they didn't have the same sorts of luxuries that we have. They're moving from a country where they didn't have as much industrialization, or, you know, there's a lot of different things we need to look at. Or they could be moving, or they could be from a culture that has a whole different set of expectations for social behaviors. So we want to, you know, kind of back up and take a look at that. Now, culture is really broadly defined. It's not just ethnicity. That's. That's only a part of culture. Culture. You know, you can really think of it as encompassing a lot of different things about what makes a person who they are and kind of shapes how they think. They generally have a common intergenerational heritage. So, you know, if you were born in the country and raised in the country out in middle Tennessee, and you move to New York City, it's going to be culture shock. There's a reason we call it that. So you've learned over the years, and your family has passed on coping skills and tools to deal with this particular culture of rural life, for example, and you don't have the skills and tools to deal with urban life right away. It takes a little while to get acculturated. Culture also shares values, beliefs, customs, behaviors, traditions, institutions, art, folklore, and lifestyle. So thinking about, again, people that come from different settings, and I use that term kind of broadly, who come to where we are, and they may be looking around going, this is a little odd. And we may, you know, not be as familiar with their background as well. They share similar relationship and socialization patterns, a common pattern or style of communication or language. And this is another one. You know, think about age groups. For example, youth who grew up communicating via text have a different communication pattern than those of us who grew up before computers were even invented. And, you know, they share different languages, if you remember, and I'm sorry if you know, it brings back, you know, nervous tics. But if you remember the 80s when we're like, oh, my gosh, like Valley Girls and everything was like, like awesome and totally wonderful. Yeah, I grew up in the 80s. I can't help it. But that was a whole different communication style and language that drove my mother up the wall. Totally, totally, totally tubular. Anyway, the. So we want to be respectful of that. You know, are these people interacting in a way that either being standoffish or being, you know, friendly or, you know, what their perceptions are or whatever, in a way that fits their culture and, you know, age plays a part in that? Geographic location of residence we've already kind of talked about. And patterns of dress and diet vary. There are certain cultures of people who have a very regimented diet and patterns of dress. Some religions, for example, don't believe in showing any skin below the neck. So being conscious of these sorts of things. And you can pick up on a lot of these clues in the initial assessment about what the person's culture is and where they're comfortable. So when we go through the personality disorder diagnoses, think to yourself, you know, different times where acculturation or culture may have made someone seem like they might have a personality symptom, when in actuality, it was just a process of acculturation. Cultural issues also can be present when minority groups, immigrants, individuals from different ethnic backgrounds, and those with physical handicaps display suspiciousness or guarded or defensive behaviors because they perceive neglect or indifference by the majority of society. So when we're looking at paranoid personality disorder, when we're looking at maybe narcissistic or antisocial personality disorder, there are some characteristics that someone who is suspicious, guarded, or defensive may project. And we want to say, you know, again, what's the function of that behavior? Where is that coming from? And is it a disorder? Or is it a protective mechanism that has, you know, sort of helped them survive? Some ethnic groups will also display culturally related behaviors, which should not be confused with paranoia, avoidance, or dependence. Some cultures are very interdependent, and there are definitely hierarchical roles in the family. Gender roles are much different in certain cultures than in others. Want to be cognizant of those things. And in December, I'm doing multiple series on several different cultures, including Asian American, Hispanic, Black, and Native American. So, you know, tune in for those if those are any of the cultures that you deal with. Issue number two, stereotyped gender roles. We don't want to misdiagnose a strong, forceful female, a very strong female person, as having antisocial characteristics. Likewise, if that person adheres to certain more traditional gender roles, we also don't want to put them in a category where we're looking at dependent characteristics. So whether or not it's how we think, you know, we would prefer to interact in society. We want to look at the broad scope of what is acceptable in our culture and is it causing the person functional distress? And males can often be labeled as antisocial or narcissistic. Again, in our culture, think about CEOs, think about heads of organizations, think about sports athletes and people who tend to be very sure of themselves and can be, again, very forceful, sometimes be somewhat manipulative in order to achieve their goals. Well, how do you think they got to be CEO without being confident and kind of all right there. Personality traits are only personality disorders when they're inflective, maladaptive, persistent, and cause functional impairment or subjective distress. Not everybody who has a personality disorder is going to experience subjective distress. And we'll kind of see that more in your schizoid and schizotypical personality disorders. Issue number three. We want to differentiate mood disorders with psychotic features from personality disorders. So paranoid, schizoid and schizotypal must not have occurred within episodes of schizophrenia, bipolar, or any sort of depressive disorder with psychotic features. So we want to make sure that it's not an enduring mood episode. Personality changes as the result of ptsd, and this is one I hadn't really thought of until I did this presentation. But when someone has ptsd, they may lose interest in social relationships where they have that emotional flattening, the detachment, sort of the withdrawal, some solitariness affect flattening. They can be kind of irritable, they can be cranky, they can have difficulty sleeping, which contributes to mood issues. They can also have, you know, hyper vigilance, that strong startle response. So they may have some agitation and irritability that goes along with it. Lack of trust and paranoia. You know, after you're exposed to a trauma of some sort, you gotta figure out how that, what that means in your world. And if it's incorporated in some people's world in terms of they see it as the world is no longer trustworthy, then they're going to exhibit more lack of trust and paranoia type symptoms that we want to be dealing with. But again, this is still PTSD stuff and PTSD can be pretty darn enduring. It has to be. Remember, acute stress disorder is the first month. So month one on is ptsd. And some people, you know, struggle with PTSD for years. So it could endure the right length of time for a personality disorder to meet personality disorder duration criteria. But we have to rule out the ptsd because remember, I said a lot of people with personality disorders, especially borderline and in my experience, antisocial, tend to have been victimized or exposed to trauma, significant trauma as children. So are they expressing PTSD? Are these personality changes as the result of PTSD, or do they have a personality disorder issue? 5. And we're going to cover this a little bit more when we talk about diagnosis of addictions. But there is such an overlap in the symptoms of addictions and personality disorders. I do want to spend a few minutes here, and I think my little icon covers this. But paranoid, schizoid, histrionic, borderline, antisocial, and dependent personalities all have a lot of things in common with people with addictions or who are not in recovery. So let's take a look at that. Remember that it has been estimated by certain meta analyses that in the US up to 47% of people struggle with addiction at some point in their life. And that can include a variety of things. Sex addiction, gambling addiction, you know, smoking, I believe, was also included in there. So that, you know, lumps in a bunch of people in addition to alcohol use and other things. But there's a lot of addictive behavior. So we want to look at what. What's common among those addictive behaviors. More time is spent getting, using and recovering from the substance than intended. So the person is sort of preoccupied with this, which means they're not paying attention to other things. They tend to lose interest in other hobbies. They may separate and withdraw from other friends and be less concerned about them. When somebody is deep in their addiction, they are not as interested in social relationships, especially not those social relationships which don't share the same addiction, because, you know, they don't. They're too busy trying to hide their addiction from people who are going to tell them that they're doing things that are bad for themselves. When somebody is in withdrawal from substances, and it could be they're trying to quit, or it could be they just haven't had any for a while. They could be irritable, very cranky, somewhat aggressive. Sometimes they can be very begrudging and everything is somebody else's fault. And they're very resentful towards a lot of people. And when people are in withdrawal, they also tend to start, if you will, sobering up and looking around at the chaos that surrounds them, either whatever problem they were running from to begin with or all the problems that they've caused, because they've been engaging in addictive behaviors for a while, and it gets very overwhelming and it's Scary as heck for a lot of these people. So they get angry and they start developing resentments of, look what you made me do. So this is sort of in the withdrawal period. We want to recognize this. But once they get past that and develop the coping skills and start weeding through and sorting through the rubble that has become their life, a lot of that tends to go away. So, you know, paranoia or irritability while under the influence, whether it's marijuana, whether it's spice, lsd, you know, there are side effects of a lot of the drugs people can take can make them somewhat paranoid or irritable, agitated. So just, you know, again, that may not be a personality disorder. It may indicate that they're currently under the influence of histrionic behaviors can come up. Overly sexualized behaviors, overly dramatic behaviors, needing to be the center of attention in order to manipulate others, to get the substance or to convince them that there's no problem. And when I ran the residential unit, there are periodically people who would come in who were drama creators. And you knew when they checked in, because we had history with them, that there was going to be some chaos. And a lot of times that chaos was created that those sort of histrionic behaviors happened, ironically, to take the focus off that person. You know, when things started getting a little hot for them or uncomfortable, they would create some kind of drama in the house, and we'd quit looking at them as much because we'd be worried about settling everything down in the house. So these things can also come up in people with addictions, dependence on dealers. You know, some people will be very compliant with their dealers in order to get what they need or get the drugs that they think they need. They may fail to meet important role obligations because they're too involved in this drug or addiction that they're. That they've got reduction in. Hobbies are important activities when it starts. You know, sometimes the high is so good, gambling or drugs or sex or whatever it is that they want to go back. So they, you know, those other hobbies kind of pale in comparison, and they focus on that. But after they do it for a while, their neurotransmitters are so far out of whack that in order to even feel normal, they almost have to keep a steady flow of that addictive behavior going on in order to keep their. Their dopamine levels and everything at a normal. At a normal rate. So we see them reducing their hobbies and important activities even more in the long run because they need to keep using in order to you know, keep going in order to feel even semi normal when they are using. You know, sometimes they will take on this addiction like it's their best friend. And they may continue to use despite knowing it's causing them problems in their life. And when this happens, they start recognizing that it's causing them problems, but they're not ready to let go. They can't let go. They're afraid to let go, whatever it is. Then they may become hypersensitive to perceived attacks on their character. If they think, think somebody's even judging them even a little bit for their use, or even thinking that they're using, they start getting very guarded and defensive, which causes interpersonal problems. We start seeing feelings of emptiness and low self esteem in people who've been, especially who've been using for a while. They start feeling hopeless and helpless. And they, you know, like when they start to sober up, they see that they've hurt people. They see what they've done. They're like, how could I have gotten to this point? Their self esteem takes a nosedive for a while and they may start feeling really empty because they see that a lot of things that were important to them, they no longer have. And there's a reluctance to combine in people and doubts about people's loyalty because the people who they did trust wanted them to stop using. They wouldn't stop. So those people may have backed off. And then they're like, well, if you're not going to bail me out of jail for the 15th time, you know, then you don't really love me. Some of that may be manipulative at some time, but a lot of times people who are, you know, steeped in their addiction actually believe that they can't see the forest for the trees. And people with addictions can be restless or irritable when not using. If they can't get their substance, they may start pacing the floor and getting really agitated. And this is true whether it's something like gambling, you know, if somebody can't go gamble, we will see these same sorts of behaviors. Internet gaming, addiction, same thing. So I don't want you to just focus on drug use. I want you to look at addictions in the bigger picture. And we want to make sure that we're catching those. Because our behavioral addictions can progress to substance addictions when the behaviors, you know, kind of aren't cutting it anymore. We often see people develop additional addictions in drug use. You know, when people start developing tolerance to one thing, they either increase the dose or start combining Drugs and sort of making a cocktail in order to enhance the effects. Same thing's true with behavioral addictions. If they're gambling and it's not really doing that, doing it for them anymore, they may gamble more or they may start combining it with something like cocaine to enhance the high. So we want to pay attention to these things because if we've got somebody who's engaging in problematic use, not even, you know, necessarily meeting diagnostic criteria, we want to pay attention to how is that affecting their personality and their social engagements. Autism spectrum disorders is another one that we often see under diagnosed. At least I can say I saw it under diagnosed because in the 15 years I worked in community mental health, I didn't see one person come through with any sort of autism spectrum diagnosis. And I know we had people come through that had to, you know, just running the percentages. So people with ASDs anywhere on the spectrum, you know, we're not going to point out specific ones right now, may have deficits in social, emotional reciprocity, nonverbal communication, relationship skills and absence of interest in peers. Deficits and imaginative play in children, of course. Hypo or hyper reactivity to stimulation. Some people may not be phased at all. Some people may be, you know, just really hyper stimulated. Insistence on sameness, inflexibility and adherence to routines and highly restricted fixated interests. So those are the things, the characteristics of ASDs that overlap with schizoid, antisocial and obsessive compulsive personality disorder. So we want to make sure to rule out some of those, differentiate it from fasd. Now, FASD is fetal Alcohol spectrum disorder, which is in the DSM called neurobehavioral disorder associated with prenatal alcohol exposure. However, whatever you want to call is not in the autism spectrum. So it's a whole different diagnosis. And then the DSM is back in the areas for further study. The one thing that you want to look at is the fact that people with fasd, and I'm going to call it that for short, because it's easier to say than the other, will have an impairment in executive functioning, planning, organization and behavioral inhibition. According to the cdc, people with FASD frequently report a history of the following sexual behaviors, starting with the most prevalent. So sexual advances. They have a difficulty interpreting nonverbal communications and respecting other people's space and inhibiting their own behavior. If they want to give you a hug, they're going to give you a hug. So inappropriate touching is very, very common. Sexual touching can be very, very common. Promiscuity exposure and certain compulsions can also are also very common in people with an fasd. And the website with the study whoops is over here. It's. Well, you can, you can see the web address if you want to go read the full study that the CDC did. But it shows that there are some functioning and impulse control deficits. Now, does it mean that the person is trying to be mean, antisocial, overly sexual, histrionic? No, it means they've got some impulse control issues. Learning, memory, visual spatial reasoning are also problematic in persons with FASDs. Mood and behavioral regulation, Attention deficit social communication. They may be overly friendly with strangers and have difficulty understanding social consequences. They have difficulty of understanding why it's not okay to just go up and hug a stranger or give somebody a kiss that you've never met before. Daily living skills and motor skills, both fine and gross, may also be impaired in persons with fasd. So we're going to look for some of these other things that are not necessarily common personality disorders and alternate conceptualizations. This is another interesting point that came out of the DSM 5. Avoidant Personality Disorder may just be an alternate conceptualization of social anxiety and phobia. So when you look at how do you differentially diagnose avoidant personality from social anxiety, they couldn't tell you. The DSM was like, they're pretty much the same thing. Antisocial and borderline personality disorder criteria can also completely overlap. Addictive disorders, especially if the addictive behavior began in childhood that is under 13 years old. Because antisocial personality disorder, you have to have the presence of conduct disorder and, and a lot of that is before the age of 13. So we want to look and see how long has this behavior been going on. But some people, and you know, people with tend to have worse addictions. More severe addictions may have started using as early as 8, 9 or 10. And that's not uncommon. So let's look at some of the personality disorders and think about how we might differentially diagnose paranoid personality disorders. First apparent in childhood with people being solitary, having poor peer relationships and social anxiety, underachievement in school, and maybe hypersensitive. So this kind of overlaps with some other personality disorders we're going to talk about as well as autism spectrum, fetal alcohol, especially in, in the early years. Paranoid personality must be present before any psychotic symptoms emerge. So if the person has schizophrenia or some other psychotic disorder, the other, they must have met the criteria for paranoid personality before those psychotic symptoms emerge. There's the criteria and you'll see down here it spells out suspect, suspective infidelity and disloyalty of people. They tend to be unforgiving and begrudging. Now this sounds a lot like addiction. People with addictions to me, suspicious of other people's motives. This could sound like addiction. It could also sound like borderline personality disorder. Perceives and quickly reacts to attacks not apparent to others. Suspicion and being highly reactive could also be personality changes as a result of ptsd. East stands for enemy or friend. Kind of not sure where people stand all the time. That's really common in people with borderline personality disorder. Confiding in others is feared. You know, just don't trust anybody. And threats perceived in benign events or remarks. So people can become hypersensitive because of trauma experience, because of poor acculturation. For whatever reason. They may feel like the world is against them. They may feel like they're being discriminated against. They may be feel begrudging and be suspicious because of poor acculturation or they're staying with their primary culture, however you want to say it. So we need to be sensitive to those sorts of things. And this is also true. Remember we said this is also true of people who have especially physical disabilities can feel like they're not getting what they need, they're not getting their needs met and that society doesn't care to meet their needs. So we want to be sensitive to where are these behaviors coming from? Schizoid personality. The person has a detached or flattened affect and seems to lack emotion. Now you'll see the acronym here is distant seem to lack emotion. They react passively to adverse circumstances. So you know, they find out they're losing their house. They're like, yeah, whatever, you know, nothing ever gets arise out of them. They're just blah. They are indifferent to criticism or praise. Sex is of little interest. Tasks are done solitarily. They tend to have an absence of close friends and they neither desire nor enjoy close relationships and take pleasure in few activities. Now, they're not introverts. Introverts love relationships. They have a couple of close friends. They don't have 50 best friends. They have a couple of really close friends and they enjoy close relationships. So it's not that, you know, we want to make sure we differentiate. Is it that they don't have friends because they don't want them or is it they don't have a whole lot of friends? And so anyway we want to differentiate there. Sex of little interest is another. That's kind of one of Those beacons that goes off if somebody is displaying this trait. However, there are some people who define themselves as asexual. So we don't want to put somebody who is asexual into the schizoid personality area unless they meet the other criteria. So sex of little interest is not in and of itself a problem. Rule out paranoid personality addiction, especially to depressants and opiates. Because, you know, people who are on depressants and opiates may seem kind of slow and flat. And honestly, if they're high, they really don't care about criticism or praise. They're just like, yeah, whatever. And sometimes you'll see this on in people who are heavy users of marijuana, sexes of little interest, absence of close friends. When people are deep in their addiction, especially if it revolves around depressants, they may not care about having other friends. It's just about them and the drug. Rule out persistent depressive disorder, antipsychotic disorders, autism spectrum disorders, because again, people with autism spectrum disorder may have difficulty with interpersonal relationships and they're overstimulating. So they don't really desire or enjoy them because it's just. It's too much to process. Schizotypal. Now, the defining features here and the acronym or mnemonic is me. Peculiar, magical thinking and experiences unusual perceptions. So it's very similar to schizoid. However, schizotypal also has the magical thinking and unusual perceptions about what is going on. Paranoid ideation, eccentric odd behavior, constricted or inappropriate affect, unusual thinking or speech, lacks close friends, ideas of reference, and anxiety in social situations. We want to rule out psychotic and developmental disorders. I can tell you in, you know, seeing people in the facilities that I have, I haven't ever seen someone who met the criteria for schizotypal. It's not that common of a diagnosis. So avoidant personality disorder. We see this a little bit more, and the acronym here is cringes. Certainty of being liked before getting involved. Rejection preoccupies thoughts. So whenever they're getting ready to get into some sort of relationship or go to a meeting or do anything that involves other people, it sort of makes them cringe because they're terrified of rejection and they don't want to let themselves get close to anybody unless they're certain it's going to go okay. Intimacy is restrained due to fear of getting shamed. Now, some people I work with have high levels of anxiety, high levels of fear of rejection, but as soon as they meet somebody, they're just like all in There are no boundaries. So that kind of differentiates them there. They kind of put it all out there. They're like, here I am, please love me. That's not the avoidant personality. Avoidant personality is very restrained in their initial relationships and with intimacy because they're afraid of shame and they're inhibited in their new relationships. Anytime something comes up where they're going to have to be around others, they try to find a way to get out of it because being around others is just too threatening. Embarrassment prevents trying new activities, new hobbies, and they view themselves as unappealing or inferior. When you're diagnosing this, you also want to rule out body dysmorphic disorder because some people with BDD will not want to be in social situations. Fear, rejection, you know, really meet a lot of these criteria. They can be co diagnosed if it exists, but it's something to be on the lookout for. Dependent personality Reliance is the mnemonic. Reassurance is required for decisions. Now think about, you know, dependence is somebody who. Is more like a child in their approach to life and constantly needing reassurance, constantly needing approval for decisions. They won't express disagreement because they don't want to be rejected. They want other people to fix it and to take on their life responsibilities. They have difficulty initiating projects. They may feel alone, helpless and uncomfortable. If they're alone, they go to excessive lengths to obtain nurturance, companionship of some sort. Another relationship is sought urgently if a close relationship ends the so they don't go from living in mom and dad's house to exploring themselves for a while to a relationship. It's generally from mom and dad's house into a relationship, into a relationship. And there's exaggerated fears of being left to care for themselves. An interesting area you want to look at and you know, again, I'll bring up the culture sort of thing is when you look at the kink, if you want to. I can't remember what the acronym is. The appropriate acronym is now for GLBTQ2 I k I believe, but K stands for kink. And when you look in the BDSM communities, there are certain people who enjoy being submissive and having a parental figure, either a daddy figure or a mommy figure. So you know, you can do more research. If you run into that and you're trying to figure out is this a personality disorder. Generally in this situation it's not causing the problem, the person problems in their, in their life, it's not causing them functional problems and it's not causing them Distress, it may or may not. These behaviors may or may not be separated and just in that one relationship, or these behaviors may be more pervasive throughout their life. So, you know, kind of taking that into consideration, we also want to differentially diagnose it from separation anxiety. In separation anxiety, the focus is specifically on being separated from the attachment figure. You know, mom, dad, primary caregiver. In dependent personality disorder, the attachment and the fear of separation is from anybody. It's very indiscriminate. They just need to be in a relationship where somebody's taking care of them. Differentiating it from generalized anxiety, the anxiety. Independent personality is almost exclusively related to fear of being left to care for themselves and not being in a relationship. Fears of rejection, more of a social nature. Antisocial personality disorder, the mnemonic is corrupt conformity to law, lacking obligations are ignored. Reckless disregard for the safety of self or others. So it's not just to others. It can be to their own self. They are just out there and wide open remorse is lacking. They can be underhanded, deceitful, lying, manipulative, very impulsive, and tend to be irritable and aggressive. A lot of people with antisocial personality disorder also tend to be very confrontational and aggressive when their wishes are blocked because they are going to get what they want when they want it. Thank you very much. Now, in order for this diagnosis to occur, they must have had symptoms of conduct disorder before age 15. Just to review conduct disorder, the person is before the age of 15, shows aggressiveness, deliberately cruel to other people or animals, property destruction, criminality. They've run away at least twice before the age of 13, and they're truant before the age of 13. So, you know, antisocial, for whatever reason, they decided this particular one has to have a much more long standing pattern of behavior. But you also want to differentiate, differentiate it from addictive disorders. We already talked about that. And mania or hypomania, but specifically mania. Because people, when they're in a manic phase can break laws. You know, they can be very, very impulsive and ignore their obligations. They are wide open. They're, you know, people in a manic phase often are not paying attention to, you know, staying on schedule. They often have a reckless disregard for safety of self and others. They may be impulsive, irritable and aggressive. Now, a lot of times in a manic episode, people still have remorse, but not always. You know, sometimes they're just not even in touch with their feelings at that point. So you want to look, remember Manic episodes are going to be episodic and personality disorder is going to be two years. So that's one of the defining features there. Borderline personality. One of my favorites to talk about the mnemonic is AM suicide. And when you've worked with someone that has borderline personality disorder you generally have an idea. They have fears of abandonment, mood instability and marked reactivity of mood. They can have suicidal or self mutilating behavior. So you know, cutting falls into this category. It doesn't just have to be suicidal. And in some cases, some people have tried to make the argument that people who have multiple plastic surgeries in order to try to get approval and love and you know, that kind of stuff because of their maybe body dysmorphia or whatever it is. Sometimes that's included. But again we want to look at culture and our culture is very pro plastic surgery in a lot of ways. So would that be considered not culturally sanctioned, unstable and intense relationships with a person with borderline personality disorder? Relationships. You never know if you're going to have Dr. Jekyll or Mr. Hyde walk out of the bedroom and you can be in the middle of a conversation and things are going well and the person with BPD perceives that they're being judged or attacked and they will turn on a dime and you will go from being the most revered to the most hated. Which makes it really difficult for anyone around someone who has borderline personality because they don't pick up on these perceived slights. So they don't know. And they're always walking on eggshells. To quote the book, trying not to set the person off. Impulsivity in two potentially destructive areas. Now I have an asterisk besides this beside this because it tends to be one of the more defining features of borderline control of anger is really difficult for the person with borderline personality. As soon as they feel attacked, they start lashing out. Identity disturbance, dissociative or paranoid symptoms and chronic feelings of emptiness. Okay, so if it's over diagnosed then what are we missing? What are we calling borderline personality disorder when it should be something else? We want to rule out major depression. In major depression people have feelings of guilt and worthlessness, emptiness, suicidal ideation and mood lability, which you know, all of which you see in people with borderline personality disorder. So even remember, depression can start in early childhood. It doesn't have to start, you know, later on in life like it does for a lot of people. Not everybody has that, you know, blessing, if you will, of not having it start till later in life. We want to rule out mania. Erratic, aggressive behavior, impulsivity and mood instability are all common in mania. So those unstable and intense relationships, impulsivity, control of anger, those may be present during a manic episode. And anxiety. We want to rule out generalized anxiety disorder which also can cause mood instability. When somebody's anxious a lot of the time they may be very irritable, they may be you know, angry one minute and then like they try to calm themselves down. They may be impulsive, have anger issues. Because remember anger and fear are two sides of the fight or flight. So if somebody's really anxious all the time, they may lash out sort of in a protective, self preservatory way. And stress related paranoid symptoms are not uncommon in people with generalized anxiety disorder. So let's look at what's going on. Because both major depressive disorder and generalized anxiety disorder can be long standing ongoing issues. Mania is going to be more episodic. But we need to look at differentially diagnosing. Can borderline and depression or borderline and anxiety occur together? Yes, they can. They can. To differentially diagnose, we want to rule out addictive disorders, depression, anxiety, but also intermittent explosive disorder, bipolar, paranoid personality, antisocial and dependent personality. Common co occurring issues according to the dsm. Depression, anxiety, bulimia and ptsd. Bulimia is really common in borderline personality disorder. PTSD is also really common co occurring. Now if we go back to one of those first issues, remember we don't want to misdiagnose some personality changes as a result of PTSD as a personality disorder. We need to look and see chicken egg kind of what's going on here. I personally, and you know, I'm not making recommendations, I'm just throwing out there self disclosure. I personally tend to steer away from personality disorder diagnoses most of the time unless it's just really right out there. Because personality disorders are perceived to be enduring things that are relatively untreatable or highly difficult to treat. And there are a lot of agencies that will not unfortunately accept patients who have a personality disorder diagnosis. And you say, well how can they do that? Because they argue that someone with a personality disorder needs a higher level of care than they can provide, especially at your residential and intensive outpatient levels. Which means a person with a personality disorder, you know, may be referred up for, you know, inpatient hospitalization before they need to, may need to meet the criteria for inpatient hospitalization before they can actually get any sort of enduring treatment. So their issues have to get really severe or they're in once a week outpatient or maybe three times a week outpatient, which isn't enough for them. So that's one of the reasons I personally, you know, unless I have just really huge mounds of evidence that a personality disorder exists, at least in the first, you know, couple months that I'm working with somebody, I try to let everything, the dust settle, figure out where we are before I even entertain the idea of a personality disorder Diagnosis Prevalence of Borderline personality now remember I said approximately 15% of the United States population meets the criteria for a personality disorder diagnosis. In the United States, the Prevalence of borderline is 6% in primary care, 10% in mental health and 20% in psych hospitals. So again, that kind of supports what I was just saying that a lot of times a person gets to the point or can't get into any program until they meet the criteria for being in a psych hospital. But you also have the fact that people with borderline personality disorder often engage in self destructive and self injurious behaviors that can get them into that place quicker. Nearly 50% of individuals with a borderline personality disorder diagnosis in early adulthood do not meet criteria 10 years later. Let that set in for a minute. That was a new tidbit that I learned doing this class. 50% of people with borderline personality disorder in early adulthood do not meet criteria 10 years later. So then was it personal? Borderline Personality disorder? Is it something that's enduring or are personality disorders easier to treat than we are thinking they are? I don't know. Many adolescents and young adults display borderline characteristics as they develop identity, adjust to independence and resolve existential conflicts. Who am I going to be when I grow up? What do I stand for? What's right, what's wrong? All that kind of stuff. And if you've worked with adolescents or you've had brothers or sisters or teenage children, you've seen this. And there are some days you're just kind of looking at them going oh my gosh, you know, bless your heart. But recognizing that they're struggling with a lot of stuff and I mean heavy stuff that people our age would be considering. Heavy stuff. But hopefully, you know, we've gone through and already answered a lot of those questions for ourselves. But they're young and they're, you know, optimistic and trying to figure out what makes the world work. Histrionic tends to be provocative or sexually seductive. Relationships are often considered more intimate than they are. They thrive on attention and are very uncomfortable when they're not the center of attention. They can be influenced easily. Now these are all really common characteristics of fetal alcohol spectrum as well. The style of speech can be impressionistic or lack detail. Emotions may be rapidly shifting and shallow. They may have a made up physical appearance to draw attention to themselves. And they tend to be pretty exaggerated and theatrical in their emotions. So we want to differentially diagnose, figure out what the motivation behind these behaviors is, are and you know, if people are seeming to not learn from their experiences, they keep doing the same, making the same mistake, having the same consequences and not, you know, getting it. I would really encourage looking at fetal alcohol spectrum issues. Narcissistic personality disorder Special. They believe themselves to be unique. They are preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love. They tend to feel entitled. They're often very grandiose in their sense of self importance and conceited and their sense of self importance and grandiosity is what differentiates narcissistic personality disorder from a lot of the other ones. They are not afraid of interpersonal exploitation. You know, that's true. And antisocial too. But in narcissistic you have that, you know, larger than life sort of I am all that and six bags of chips. They tend to be arrogant and lack empathy. You want to differentially diagnose with psychotic disorders, especially those that have delusions of grandeur. Antisocial personality. And again, that manic episode comes back. And finally, obsessive compulsive disorder. The person loses the point of the activity due to preoccupation with detail. They have difficulty completing tasks because they're too perfectionistic. They have difficulty discarding worthless objects. Their friendships are often excluded due to a preoccupation with work. They're inflexible, scrupulous and over conscientious on ethics, values or morality, which is not accounted for by religion or culture. One of those people who's by the book and this is the way it's got to be. Reluctance to delegate unless others submit to exact guidelines. This is how it has to be done. They can be miserly toward themselves and others and very stubborn and rigid. If you've ever watched the TV show Monk, they did a very good character development of someone with obsessive compulsive personality disorder. You want to differentially diagnose with autism spectrum social anxiety. Schizoid personality. Obsessive compulsive disorder where the person has true obsessions. They're thinking about something like germs or the stove is on and they have A true obsessive compulsive interaction there and hoarding disorder. So personality disorders represent a long standing and pervasive pattern of behavior which causes impairments in psychosocial functioning. It has to cause impairments first, not necessarily distress, but or distress. So even if it's not causing impairments, if it's causing the person distress for some reason, then we're still looking at it meeting the criteria as long as it's been at least two years. Many people with uncontrolled mood and or psychotic disorders may display symptoms resembling personality disorders. So we want everything else to shake out first before we start looking at personality disorders. For a personality disorder to be diagnosed, the other conditions must be brought into remission and or the pattern of personality disordered behavior existed before the onset of the mood or psychotic features, which, you know, you may be going way back. You may not even have a historian who can go back that far reliably for you. Many treatment centers have restrictions against admission of persons with personality disorders, asserting they need a higher level of care. But then those people, once they get out of psychiatric hospitals, where do they step down to? Because again, the person with a personality disorder is often treated, unfortunately, more like the hot potato. So as a profession, I think we need to look at some of the research that shows that, you know, Sometimes, you know, 10 years later, 50% of people with borderline personality disorder no longer meet the criteria. So what is that telling us? And what new treatments, what best practices like DBT do we have that we can help people with personality disorders develop the skills and tools they need to go into remission? If you want to say that with the personality disorder. Okay, well, thank you for bearing with me. We have completed our presentation on personality disorders. Does anybody have any questions? That data I gave you at the beginning of class is not on the quiz. It's not, you know, information that I think is crucial to helping you make effective diagnoses. I just thought it was really interesting how it broke down and that borderline personality disorder wasn't even in the, you know, top five. Alrighty. Well, I really appreciate you guys being here today and I will see you on Tuesday. Have an amazing weekend and hope everybody starts getting ready for turkey day. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allceus.com counselortoolbox this episode has been brought to you in part by allce.com, providing 24. 7 multimedia continuing education and pre certification training to counselors, therapists and nurses since 2006. Use coupon code counselortoolbox to get a 20% discount off your order this month.