Chapter 42: Personality Disorders
A 50-year-old man is scheduled for a routine colonoscopy. As plans are made for postprocedure care, he says he has no close friends who can help. He is estranged from his family, who no longer invite him to gatherings because he does not seem to enjoy them and prefers to play video games. He lives alone and has never married or even had a significant dating relationship, going back to high school. He works as a truck driver, spending weeks on the road by himself. He has been through several jobs and had difficulty maintaining any that involved working closely with others. In conversation, he is somewhat cold and detached but otherwise seems appropriate. When asked why he has few friends, he says he just “doesn’t see the point.” Which of the following is the most likely diagnosis?
A. Avoidant personality disorder
B. Schizoid personality disorder
C. Schizotypal personality disorder
D. Paranoid personality disorder
E. Antisocial personality disorder
B. The patient has no significant interest in developing long-term relationships, which is a long-term pattern of behavior for him and results in impaired social and occupational performance. The difference from schizotypal personality disorder, another Cluster A disorder, is that this patient has no desire for relationships and does not appear particularly unusual in terms of his demeanor and beliefs; those with schizotypal personality disorder may seek relationships, but their odd and eccentric behavior impairs their ability to form them. His impaired relationships are not due to suspicion or perceived threats from others, as in the other Cluster A disorder, paranoid personality disorder. The history is not consistent with antisocial personality disorder (Cluster B), which is characterized by a disregard for rules and unethical behavior; this patient does not seem to disregard the rights of others, but he just is not interested in having relationships with them. The history is also not consistent with avoidant personality disorder (Cluster C) because the patient is not avoiding relationships due to a fear of rejection or sense of inferiority.
A 32-year-old woman presents to the emergency department after a sleeping pill overdose. She says her boyfriend recently broke up with her. Apparently the relationship had formed a couple months before and become serious shortly after they had met, and ended because the boyfriend found her too volatile after several episodes when she became enraged about seemingly minor issues. The patient acknowledges a feeling of emptiness and says she has a difficult time controlling her temper. She has several prior hospitalizations for self-injurious behavior including cutting herself, dating back to college. Which of the following is the most appropriate diagnosis?
A. Narcissistic personality disorder
B. Histrionic personality disorder
C. Dependent personality disorder
D. Borderline personality disorder
E. Schizotypal personality disorder
D. The patient has a history of volatile emotional states, unstable relationships, episodes of intense anger and rage, and self-injurious behavior, all of which are typical of borderline personality disorder. She does not have the arrogance and grandiosity associated with narcissistic personality disorder or the history of attention-seeking provocative behavior and seductive appearance associated with histrionic personality disorder, other Cluster B diagnoses. She does not have the bizarre beliefs and peculiar behavior and speech patterns typical of schizotypal personality disorder (Cluster A) or the passive, submissive nature or difficulty making decisions typical of dependent personality disorder (Cluster C).
What is most likely to be an effective approach to treating the patient in Question 2?
A. Dialectical behavioral therapy
C. A combination of citalopram and olanzapine
D. Psychodynamic psychotherapy
E. Both dialectical behavioral therapy and psychodynamic psychotherapy have shown benefit for borderline personality disorder in randomized trials. Although pharmacotherapy can be used as an adjunct to therapy, neither first-generation neuroleptics nor polypharmacy would be an ideal choice.