Adjustment, Personality Disorders & Chronic Medical

Conditions

• Jeff Baker, Ph.D.• Chief Psychologist, Anesthesiology, Orthopaedics &

Rehabilitation, Surgery

• Director, SAHS Counseling & Student Services

Objectives

• Identify psychological influences of personality.

• Understand the influence of stress on personality.

• Types of Stressors that influence patients’ rehabilitation.

• Effective ways of managing patients with major psychosocial stressors

Personality Disorders & Stress

• Adjustment Reactions to Medical Conditions

• PTSD• Long Term Effect• 11 Personality Disorders (DSMIV TR)• Differentiation of Personality Disorders• Case Studies & Managing Psychosocial

stress.

Adjustment Disorders

• Development of emotional or behavioral symptoms in response to an identifiable stressor(s) within 3 months of the onset of the stressor(s).

• Evidenced by either of the following:

Adjustment Disorders

• 1. Marked distress that is in excess of what would be expected.

• 2. Significant impairment in social or occupational functioning.

Adjustment Disorders

• The stress-related disturbance does not meet the criteria for another AXIS I or AXIS 2 disorder.

• The symptoms do not represent bereavement.

• Once the stressor has terminated, the symptoms do not persist for more than an additional 6 months.

Adjustment Disorders

• 309.0 Adj Disorder with Depressed Mood

• 309.24 Adj Disorder with Anxiety

• 309.28 with mixed anxiety and depression

• 309.3 with disturbance in conduct

• 309.4 with disturb of emotions and conduct

• 309.9 Adj Disorder unspecified

Posttraumatic Stress Disorder

• The symptoms develop after a psychologically traumatizing event or events outside the range of normal human experience. May experience symptoms alone or in groups. The stressors contain a psychological component and frequently a concomitant physical component that may directly damage people's nervous systems. In adjustment disorder the precipitating stress event need not be severe or unusual.

Personality Disorders & Effect on the Individual

WithoutTreatment

Depression

Phobias

Elevated family violence

Drug use

Exacerbation of Existing Issues

Inhibit Healing & Rehabilitation

Identifying Personality Disorders

1. What are the characteristics of a person that would warrant a personality disorder diagnosis?

2. How would that effect my ability to provide treatment/therapy for the patient?

3. How is this going to effect the patient’s quality of life.

Mini Self-Test

Definition of Personality Disorder

1. It is pervasive and inflexible.2. It has an onset in adolescence or early adulthood.3. It is stable over time.4. It leads to distrust or impairment.5. P.D. Is thought to be an enduring pattern of inner experience

and behavior that deviates markedly from the expectations of the individual’s culture.

6. Coping or defense mechanisms, which are used to deal with high levels of stress that have been left untreated.

7. Coping with pain, loss of identity, mobility, and independence all may have profound effects on personality.

What are Personality Disorders Like?

• People with personality disorders typically have problems in many areas of their lives, including social skills, moods, and emotional states. People with these disorders have difficulty establishing normal, health relationships.

Personality Disorders

• In many of the disorders, sufferers lack the ability to have genuine emotions including empathy for others.

• In some disorders, some have no desire to have social relationships or they want relationships, but are scared to reach out to people.

• Personality disorder symptoms stem from basic personality traits that developed over time. A person does not “get” a personality disorder.

Personality Disorders

• Because personality disorder traits are deeply ingrained in the personality, there is no quick treatment. Treatment is typically based on psychotherapy which evaluates faulty thinking patterns and teaches new thinking and behavior patterns.

• A problem in treating individuals with personality disorders is that many do not believe they have a problem.

Diagnosis Criteria

1) There are 10 personality disorders listed in the DSM-IV.

2) DSM-IV = Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, TR APA 2001.

3) The criteria for each Personality Disorder is listed in the DSM-IV TR.

Differentiation of Personality Disorder and Disorder

• Personality Disorder tends to be EgoSyntonic

• Disorder tends to be EgoDystonic

Types of Personality Disorders

Cluster A: Odd or Eccentric1. Paranoid Personality Disorder2. Schizoid Personality Disorder3. Schizotypal Personality Disorder

Cluster B: Dramatic, Emotional, or Erratic

4. Antisocial Personality Disorder

5. Borderline Personality Disorder

6. Histrionic Personality Disorder

7. Narcissistic Personality Disorder

Cluster C: Anxious or Fearful

8. Avoidant Personality Disorder9. Dependent Personality Disorder10. Obsessive-Compulsive Personality

Disorder

Personality Disorder NOS

Diagnosis

Case Examples

• Patient who is verbally abusive and aggressive to staff and family.

• Patient who is suspicious and questions your treatment methods.

• Patient who wants to go have a cup of coffee with you and be your friend.

Case Examples

• Patient who is seductive and always seems dressed up and wearing lots of cologne when they come in for appointment.

• Patient who cries and appears very sad about their future.

• Patient who denies that their SCI will bring about any changes in their lifestyle.

Psychological Factors Affecting Medical Condition

• A general medical condition• Neurotransmitter Response to Stress

• Endocrine Response to Stress

• Immune Response to Stress

• Psychological factors adversely affecting the medical condition• Disorder; Psych symptoms; Personality traits;

Maladaptive health behaviors; Stress related physiological response; Other (cultural; religious)

Major Medical Issues

• Gastrointestinal System• Cardiovascular System• Respiratory System• Endocrine System• Skin Disorders• Musculoskeletal System• Headaches• Psycho-oncology

Example: Chronic Pain

• Explain the nature of the pain

• Maximize placebo effect

• Explain realistic expectations• degree and course of pain• analgesic, reframe side effects

Chronic Pain

• Chronic pain requires special arrangements:• Eliminate doubts about the availability of meds.• No meds requiring proof of need (lost, stolen)• Focus on strengths, do not reinforce obsession

with pain.• Do not make contact with cared system

contingent on pain; remove that contingency.

T Score of 50=Mean; >65 T Score Clinical Elevation

Clinical Use of the MMPI2 & Patients with Chronic Pain

30

40

50

60

70

80

90

100

110

120

Hs D Hy Pd Mf Pa Pt Sc Ma Si

"Normal"

Chronic Pain

Psychopathology

Litigation

Conclusions on PD

• Individuals Diagnosed with Personality Disorders vs Individuals with exacerbated Stressors

• Difficult to Treat, Difficult to Manage

• How Does it Affect Your Treatment of the Patient

Disorders of Impulse