Overview of the personality disorders, including the DSM5 alternative model, with particular focus on how these disorders impact the disability review process.

1. Personality Disorders in the
Disability Review Process
David D. Nowell, Ph.D.

2. Overview
• Domains of dysfunction
• Causes of personality disorder (PD)
• Treatment considerations
• Diagnosis of PD
• “Clusters”
• Alternative DSM-5 model of PD
• What we look for (and avoid) in the chart review
• Following our regulations around PD
• Q & A & D

3. 1 2 3 4

4. “Personality”
Enduring pattern of thinking, feeling, and
behaving

6. Major domains of dysfunction
1. Distorted thinking patterns
2. Problematic emotional responses
3. Over- or under-regulated impulse control
4. Interpersonal difficulties

7. Examples of distorted thinking
• extreme black-or-white thinking patterns
• patterns of idealizing then devaluing other
people or themselves
• patterns of distrustful, suspicious thoughts
• patterns that frequently include unusual or
odd beliefs that are contrary to cultural
standards
• patterns of thoughts that include perceptual
distortions and bodily illusions.

8. Examples of problematic emotional
responses
• Emotional constriction, indifference
• Fear of being ridiculed
• Fears of being abandoned
• Numbness, detachment
• Intensity, easily overwhelmed

10. Impulse Control Problems
• Over-controlled, restricted
• Impulsive spending, risky sexual behavior
• Binge eating
• Regulation of strong affect

12. Examples of interpersonal difficulties

13. Causes of Personality Disorder
• Biological factors
• Early experiences

14. King-Casas et al. (2008)

15. Gregory, S. et al. (2012)

16. Schulze et al. (2013)

20. Disorders that contribute to impaired insight
• Drug and alcohol
dependence
• Mania
• Psychosis
• Personality
disorders
• Delirium
• Dementia
• ADHD
• Conversion disorder

22. Treatment
• Pharmacotherapy
• Psychotherapeutic approaches

23. Pharmacotherapy
1) Manage co-occurring disorders
2) Reduce discomfort until they can make lasting
changes
3) Promote a more rapid experience of recovery,
which may increase motivation for other
treatment
4) Increase ability to attend therapy and
participate in a meaningful way
5) Manage symptoms which might interfere with
the ability to learn and practice new skills

27. Treatment considerations
• How optimistic can we be?
• Why don’t they just stop it?
• What is the presenting complaint?

28. Diagnosis of personality disorder
A. Enduring pattern of experience and behavior
manifested in cognition or affectivity or
interpersonal functioning or impulse control
B. Pervasive pattern
C. Clinically significant distress or impairment
D. Long duration, onset in adolescence or early
adulthood
E. Not better accounted for by another disorder
F. Not attributable to effects of a substance or a
medical condition

29. Cluster A
• Paranoid
• Schizoid
• Schizotypal

30. Cluster B
• Antisocial
• Borderline
• Histrionic
• Narcissistic

31. Cluster C
• Avoidant
• Dependent
• Obsessive-compulsive Personality Disorder

32. Diagnosis of personality disorder
• Looking for the “footprints in the butter”
– Work history
– Relationship history
• Mental status exam
• Clinicians’ response to the claimant
• Treatment team interactions (splitting)
• Our response to the chart

34. Diagnosis of personality disorder
• Features of the history vs presentation in the
diagnostic interview
– Countertransference?

35. Alternative DSM-5 Model for
Personality Disorders
General Criteria for Personality Disorder
• Impairment in personality (self/interpersonal) functioning.
• One or more pathological personality traits.
• Inflexible and pervasive across a broad range of personal
and social situations.
• Stable across time, with onsets that can be traced back to
at least adolescence or early adulthood.
• Not better explained by another mental disorder.
• Not solely attributable to the physiological effects of a
substance or another medical condition.
• Not understood as normal for an individual’s
developmental stage or sociocultural environment.

36. Alternative DSM-5 Model for
Personality Disorders
General Criteria for Personality Disorder
• Impairment in personality (self/interpersonal) functioning.
• One or more pathological personality traits.
• Inflexible and pervasive across a broad range of personal and social
situations.
• Stable across time, with onsets that can be traced back to at least
adolescence or early adulthood.
• Not better explained by another mental disorder.
• Not solely attributable to the physiological effects of a substance or
another medical condition.
• Not understood as normal for an individual’s developmental stage
or sociocultural environment.

37. Alternative DSM-5 Model for
Personality Disorders
Elements of personality functioning
• Self:
– 1. Identity: Experience of oneself as unique, with clear boundaries
between self and others; stability of self-esteem and accuracy of self-appraisal;
capacity for, and ability to regulate, a range of emotional
experience.
– 2. Self-direction: Pursuit of coherent and meaningful short-term and
life goals; utilization of constructive and prosocial internal standards of
behavior; ability to self-reflect productively.
• Interpersonal:
– 1. Empathy: Comprehension and appreciation of others’ experiences
and motivations; tolerance of differing perspectives; understanding
the effects of own behavior on others.
– 2. Intimacy: Depth and duration of connection with others; desire and
capacity for closeness; mutuality of regard reflected in interpersonal
behavior.

38. Alternative DSM-5 Model for
Personality Disorders
General Criteria for Personality Disorder
• Impairment in personality (self/interpersonal) functioning.
• One or more pathological personality traits.
• Inflexible and pervasive across a broad range of personal
and social situations.
• Stable across time, with onsets that can be traced back to
at least adolescence or early adulthood.
• Not better explained by another mental disorder.
• Not solely attributable to the physiological effects of a
substance or another medical condition.
• Not understood as normal for an individual’s
developmental stage or sociocultural environment.

39. Alternative DSM-5 Model for
Personality Disorders
Pathological personality trait domains
• Negative affectivity (vs. stability)
• Detachment (vs. extroversion)
• Antagonism (vs. agreeableness)
• Disinhibition (vs. conscientiousness)
• Psychoticism (vs. lucidity)

41. Alternative DSM-5 Model for
Personality Disorders
Pathological personality trait domains
• Negative affectivity (vs. stability)
• Detachment (vs. extroversion)
• Antagonism (vs. agreeableness)
• Disinhibition (vs. conscientiousness)
• Psychoticism (vs. lucidity)

42. Alternative DSM-5 Model for
Personality Disorders
Pathological personality trait facets
• Antagonism (vs. agreeableness)
– Manipulativeness
– Deceitfulness
– Grandiosity
– Attention seeking
– Callousness
– Hostility

43. Alternative DSM-5 Model for
Personality Disorders
Specific personality disorders
1. Antisocial
2. Avoidant
3. Borderline
4. Narcissistic
5. Obsessive-Compulsive PD
6. Schizotypal
7. Personality Disorder – Trait Specified

44. Alternative DSM-5 Model for
Personality Disorders
Let’s look at Borderline PD through this lens…

45. Elements of personality functioning
• Self:
– 1. Identity:
– 2. Self-direction:
• Interpersonal:
– 1. Empathy:
– 2. Intimacy:

46. Pathological personality trait domains
• Negative affectivity (vs. stability)
• Detachment (vs. extroversion)
• Antagonism (vs. agreeableness)
• Disinhibition (vs. conscientiousness)
• Psychoticism (vs. lucidity)

47. What we look for in record review
• Formal diagnosis of personality disorder
– With description of functional impairment
• Functional impact of co-occurring conditions
– PTSD
– Mood disorders

48. What we avoid in record review
• Punitive responses
• Counter-transference

49. Following our regulations around PD
• Document all diagnoses per problem list
development guidelines
• Provide full documentation on all applicable
listings/standards and reference at step IIIA or IIIB
of worksheet- including L(8) and 12.08 as
appropriate
• Assuring that functional impact of PD is
addressed in psych RFC
• What if no dx of PD is offered but is suspected?

50. Q & A & D