PERSONALITY DISORDERS
From the 7th Annual Psychiatry Review: The Impulsive-Compulsive Spectrum, presented by the University of
Minnesota Medical School
| ANTISOCIAL PERSONALITY DISORDER —Donald W. Black, MD, Professor of Psychiatry, Roy J. and Lucille
A. Carver College of Medicine at the University of Iowa, Iowa City
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| Antisocial personality disorder: myths—“it doesn’t exist”; “it’s just bad behavior”; “improvement is impossible”;
repercussions of myths—disorder largely ignored by mental health professionals and rarely diagnosed or
studied (although in United States, only major depressive disorder more prevalent); patients rarely offered treatment;
truths about antisocial personality disorder—culturally universal; high morbidity and mortality; enormous
costs, especially in criminal justice system
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| Definitions: informal definition—disorder of lifelong, serial misbehavior; more formal definition—pattern of recurrent
antisocial, delinquent, or criminal behavior that starts in childhood or early adolescence, and is manifested
by disturbances in many areas of life, (eg, family relations, schooling, work, military service, and marriage); alternate
terms—sociopathic personality; sociopathy; psychopathic personality; psychopathy; “antisocial does not
mean being shy or inhibited [it] means that the person is antisociety and constantly violates societal norms”
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| Prevalence and risk factors: ≈2.5% to 3.5% of adult population in United States has antisocial personality disorder;
disproportionate prevalence among prisoners (40% to 80%), homeless individuals (≈25%), and substance
abusers (10% to 50%); second most common psychologic disorder in United States (not including substance abuse
disorders);risk factors—male sex (2 to 7 times more common in men); low socioeconomic status; adoption (disproportionately
high prevalence among adults adopted as children; relationship between adoption and development
of antisocial personality disorder unknown)
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| Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for antisocial personality
disorder: A) pervasive pattern and disregard for rights of others since 15 yr of age; ≥3 of the following:
1) failure to conform, 2) deceitfulness, 3) impulsivity/failure to plan, 4) irritability/aggressiveness, 5) reckless disregard,
6) consistent irresponsibility, 7) lack of remorse; B) ≥18 yr of age; C) conduct disorder before 15 yr of age;
D) schizophrenia/mania ruled out
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| Age-appropriate symptoms: children and adolescents—behaviors associated with conduct disorder (eg, getting
into fights with other children, vandalism, lying to parents and teachers, teen delinquent behaviors); adults—
criminality; domestic abuse; irresponsibility; work problems; substance abuse
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| Lack of conscience and/or remorse: individuals with antisocial personality disorder know about the concepts of
conscience and remorse, but they do not experience them personally; in words of one author (Rule, 2000), “conscience
is a factor that separates us from animals; it allows us to love, to feel another’s pain, and to grow; whatever
the drawbacks, the rewards are essential to living in a world with other human beings ; the psychopath might as
well be a visitor from another planet struggling to mimic the feelings of those he encounters”
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| Course and outcome: behaviors begin early (≈5 yr of age); chronic and lifelong disorder; 25% to 40% of children
with conduct disorder develop antisocial personality disorder; some evidence of “burnout” (ie, attenuation) by late
30s to early 40s; prognostic factors (determined by 30-yr follow-up study)—severity of childhood symptoms; age
at follow-up (disorder generally tends to improve with time); marriage (those who marry have better prognoses, but
marriage may indicate less severe symptoms at outset); early incarceration (those incarcerated at earlier age have
better prognoses; but therapeutic aspect of incarceration not identified); prognostic factors (from speaker’s
study)—severity of adult syndrome at outset (directly correlated with severity at follow-up); age at follow-up (patients
older at follow-up were doing better); abstinence from alcohol; time elapsed since hospitalization (symptoms
improved as time increased) ; caveat—even when individual with antisocial personality disorder improves, he or
she always remains behind peers in education, occupation, marriage, and family life; comorbidity—“is the rule”;
common comorbidities include substance use disorders (alcohol abuse, ≈70%), mood disorders (lifetime depression,
≈25%), anxiety disorders, attention-deficit disorder, pathological gambling, and sexual deviancy
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| Theories of etiology: genetic theories—20% of first-degree relatives have disorder; high concordance in identical
twins; adoption studies show biologic background likely indicator for development of antisocial personality disorder;
biologic theories—brain injury; abnormal neurodevelopment; unresponsive nervous system; low serotonin;
high testosterone; all biologic theories have some data to support them; damaged brain theory has most evidence
(at least in subset of patients); history of head injury and abnormal findings on electroencephalogram common; imaging
shows decreased prefrontal gray matter and changes in limbic system; social theories—poor parental bonding;
poor parenting; abuse by parents; poor social environment; bad peers; media violence; bottom line—like other
psychiatric disorders, antisocial personality disorder likely has multifactorial origin, and probably involves genetic
vulnerability interacting with nongenetic factors
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| Treatment: no standard treatment or approved medication; no role for psychiatric hospitalization, unless patient
suicidal or in need of substance abuse services; no randomized controlled trials published, so conclusions about
treatment (or inability to treat) cannot be made
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 | Management: managing psychiatric comorbidities (especially substance abuse) helps control antisocial behavior;
no medication targets antisocial personality disorder; no particular medication routinely used; none approved by
Food and Drug Administration (FDA); several drugs shown to reduce aggression
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| Medication in specialized populations: most medication advice based on highly specialized populations; some data
from randomized controlled trials; prisoners—lithium and phenytoin associated with reduced aggression; children
with conduct disorder—lithium, haloperidol, and divalproex; personality disorders—antipsychotics,
mood stabilizers, antidepressants, and anxiolytics; brain injury—antidepressants
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| Psychotherapy: cognitive-behavioral treatment sometimes appropriate for mild cases; group therapy inappropriate;
marriage and family therapy, support groups (eg, Alcoholics Anonymous [AA] or Gamblers Anonymous) and/or
short-term community-based delinquency treatment programs may help
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| Problems in psychotherapy: patients—lack of motivation; lack of cooperation; poor follow-through; lack of insight;
countertransference; therapists—“among therapists’ most common emotional reactions to antisocials is a
feeling of fear”
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| Possible prevention strategies: targeting children with high-risk conduct disorder; early adjudication may help;
parental-effectiveness training; social cognitive-skills training; note—children without conduct disorder do not develop
antisocial personality disorder
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| IMPULSIVITY IN BORDERLINE PERSONALITY DISORDER (BPD)—S. Charles Schulz, MD, Professor and
Head, Department of Psychiatry, University of Minnesota Medical School, Minneapolis
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| Introduction: impulsivity core symptom of BPD; manifestations include gambling, spending money irresponsibly,
binge eating, substance abuse, engaging in unsafe sex, and driving recklessly; impulsivity may disrupt relationship
between patient and therapist
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| Hypotheses to explain impulsivity in patients with BPD: low levels of serotonin; diminished effortful control
(insufficient to prevent impulsive behaviors); behavioral addictions may appear as impulsivity, but might
actually have different mechanism (eg, opioid pathways); comorbid disorders (eg, bipolar disorder) may lead to
impulsive behavior
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| Approaches to psychobiology of personality disorders: study designed to explore normal attention and temperament
used imaging to investigate metabolic activity in brains of patients with BPD; authors hypothesized that
patients with BPD have high negative affect and low effortful control; findings indicated that deficit in executive
attention could lead to core deficit of BPD in person with high negative affect; another study using positron emission
tomography (PET) found significant inverse correlation between brain metabolic rates (in anterior-medial
frontal cortex and right temporal lobe) and aggressive-impulsive tendencies in patients with personality disorder
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| Selective serotonin reuptake inhibitors (SSRIs): study looked at effects of fluoxetine in patients with BPD
and schizotypal personality disorder; results suggested serotonergic dysregulation in both disorders, but must be
viewed with caution because of open design; another study found fluoxetine (compared to placebo) associated with
reduction in anger in patients with BPD (finding independent of drug’s effect on mood); third study found fluoxetine
reduced irritability and aggression in patients with impulsive aggression; speaker concludes that when used in
combination with psychotherapy, SSRIs may benefit patients with BPD; relatively high doses often required to
achieve effect
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| Atypical antipsychotic medications: typical antipsychotic agents effective at controlling symptoms, but patients
found adverse effects intolerable; data indicate that some atypical antipsychotics stimulate dopamine metabolism in
frontal cortex, possibly increasing effortful control; olanzapine—study showed olanzapine reduced symptoms associated
with BPD, helped with impulsivity, and was well tolerated by patients; follow-up study found olanzapine
better than placebo for all symptoms (eg, anger, impulsivity, interpersonal difficulties) except depression; weight
gain modest; authors concluded that olanzapine helpful for patients with BPD; at dose of 7 mg/day, no complaints
of “feeling slow” or of being tremulous, but weight gain occurred; other studies confirm these findings; olanzapine-fluoxetine
combination—as good as olanzapine alone and better than fluoxetine alone; other useful agents—
risperidone, at doses about one half those used in schizophrenia, associated with decreased aggression; quetiapine
(200 to 300 mg/day) associated with decreased depression, anxiety, and impulsivity; aripiprazole associated with
reduced expression of anger
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| Anticonvulsant mood stabilizers: divalproex—most studied anticonvulsant; studies showed improved interpersonal
sensitivity, anger, hostility, and overall aggression (independent of effect on mood); another study found it
treated impulsivity and aggression only in patients with cluster B traits
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| Omega-3 fatty acids: preliminary reports showed benefit in patients with mood disorders; 2003 study showed safe
and effective in women with BPD; patients expressed preference for omega-3 fatty acids over medication classes
discussed above
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| Behavioral addiction: proposed theory suggests that individuals who cut themselves feel no pain; opiate antagonists
may reduce self-injurious behavior if they cause patient to feel pain when cutting self; another hypothesis suggests
addiction to self-injurious behavior, and opiate antagonists might help; one study found naltrexone helpful in
reducing self-injurious behavior
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| Conclusions: impulsivity prominent in patients with BPD, but different pathophysiologic underpinnings of this behavior
likely exist; multiple classes of medicine decrease impulsive symptoms and other symptoms in patients with
BPD; combination with psychotherapy beneficial; reduction of impulsivity not correlated with changes in mood
symptoms, so medication effect not likely secondary to treating comorbid mood disorders
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Educational Objectives
| The goal of this program is to educate the listener about the diagnosis and treatment of personality disorders. After
hearing and assimilating this program, the clinician will be better able to:
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| 1. Identify patients with antisocial personality disorder and differentiate it from shyness or being inhibited.
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| 2. Discuss the course and outcome of antisocial personality disorder.
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| 3. Describe the roles of psychopharmacology and psychotherapy in the treatment of antisocial personality disorder.
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| 4. Assess the role of impulsivity in borderline personality disorder (BPD).
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| 5. Select medications that might attenuate impulsivity in patients with BPD.
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Discussed on This Program
Aripiprazole [Abilify]
Divalproex sodium [Depakote, Depakote ER]
Fluoxetine HCl [Prozac, several others]
Haloperidol [Haldol, Haldol Decanoate 50, Haldol Decanoate 100]
Lithium [Eskalith, several others]
Naltrexone HCl [ReVia]
Olanzapine [Zyprexa, Zyprexa Intramuscular, Zyprexa Zydis]
Olanzapine and fluoxetine HCl [Symbyax]
Phenytoin [Dilantin Infatab, Dilantin-125]
Quetiapine fumarate [Seroquel]
Risperidone [Risperdal, Risperdal Consta, Risperdal M-TAB]
Suggested Reading
Adityanjee, Schulz SC: Clinical use of quetiapine in disease states other than schizophrenia. J Clin Psychiatry
63(Suppl 13):32, 2002; Asberg M et al: “Serotonin depression”—a biochemical subgroup within the affective
disorders? Science 191:478, 1976; Bellino S, Paradiso E, Bogetto F: Efficacy and tolerability of quetiapine in
the treatment of borderline personality disorder: A pilot study. J Clin Psychiatry 67:1042, 2006; Berlin HA, Rolls
ET, Iversen SD: Borderline personality disorder, impulsivity, and the orbitofrontal cortex. Am J Psychiatry
162:2360, 2005; Black DW, Braun D: Antisocial patients: a comparison of those with and those without childhood
conduct disorder. Ann Clin Psychiatry 10:53, 1998; Black DW, Larson CL: Bad Boys, Bad Men: Confronting
Antisocial Personality Disorder. New York: Oxford University Press USA, 1999; Burt SA et al: The different
origins of stability and change in antisocial personality disorder symptoms. Psychol Med Oct 19; 2006; Goldstein
RB et al: Antisocial personality disorder with childhood- vs. adolescence-onset conduct disorder: results from the
National Epidemiologic Survey on Alcohol and Related Conditions. J Nerv Ment Dis 194:667, 2006; Hare RD:
Psychopathy: a clinical and forensic overview. Psychiatr Clin North Am 29:709; 2006; Linnoila M et al: Low cerebrospinal
fluid 5-hydroxyindoleacetic acid concentration differentiates impulsive from nonimpulsive violent behavior.
Life Sci 33:2609, 1983; McCord WM: Psychopathy and Delinquency. New York: Grune & Stratton, 1956;
Paris J: The development of impulsivity and suicidality in borderline personality disorder. Dev Psychopathol
17:1091, 2005; Robins LN: Deviant Children Grown Up: A Sociological Study of Sociopathic Personality. New
York: William & Wilkins Co.; 1966; Rothbart MK et al: Developing mechanisms of temperamental effortful control.
J Pers 71:1113, 2003; Rule A: The Stranger Beside Me. New York: Signet, 1980; Schulz SC: New antipsychotic
medications: more than old wine and new bottles. Bull Menninger Clin 64:60, 2000.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
Dr. Black disclosed that he is a consultant for Shire; is on the Speakers’ Bureaus of Forest Laboratories, Pfizer, and
Shire; receives grants/research support from Forest Laboratories, Nellie Ball Trust Fund, National Institute on Drug
Abuse, National Institute of Mental Health, and Shire; and receives honoraria from Forest Laboratories, Pfizer, and
Shire. He discussed the off-label use of several medications. Dr. Schulz disclosed that he is a consultant for, and is on
the Speakers’ Bureau of, AstraZeneca and Eli Lilly; receives grants/research support from AstraZeneca, Eli Lilly, and
Abbott; and receives honoraria from AstraZeneca. He discussed the off-label use of several medications.
Drs. Black and Schulz were recorded at the 7th Annual Psychiatry Review: The Impulsive-Compulsive Spectrum, held
September 25-26, 2006, in Minneapolis, and presented by the University of Minnesota Medical School. The Audio-
Digest Foundation thanks the speakers and the University of Minnesota Medical School for their cooperation in the
production of this program.
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