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8 Errors in Effective Differential Diagnosis of Personality Disorders
Instructor: Dr. Dawn-Elise Snipes, PhD
Executive Director:, Counselor Education and Training
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery

~ Review the criteria for
~ Paranoid
~ Schizoid
~ Schizotypal
~ Antisocial
~ Borderline
~ Histrionic
~ Narcissistic
~ Avoidant
~ Dependent
~ Obsessive Compulsive
~ Identify 8 common errors in diagnosis

Overview of Personality Disorder Diagnosis
~ Enduring pattern of inner experience and behavior that deviates markedly from cultural expectations in 2 or more areas
~ Cognition
~ Affectivity (range, intensity, lability, appropriateness)
~ Interpersonal functioning
~ Impulse control
~ Behavior is inflexible and pervasive
~ Behavior is stable and can be traced back to adolescence or early adulthood
~ Not better explained as a manifestation of consequence of another mental disorder or attributable to medical conditions or substances: (Mania, Addiction, Autism Spectrum, FASD)
~ Dx of a PD in someone under 18 requires a duration of at least 1 year
~ Adopted as well as biological children have similar chances of developing a PD indicating the influence of environment
Issue 1: Acculturation
~ Do not confuse with problems with acculturation
~ Take into account individual’s cultural background (ethnicity, country, urban/rural, high/low SES, religion)
~ Common intergenerational heritage
~ Shared values, beliefs, customs, behaviors, traditions, institutions, arts, folklore, and lifestyle.
~ Similar relationship and socialization patterns.
~ A common pattern or style of communication or language.
~ Geographic location of residence (e.g., country; community; urban, suburban, or rural location).
~ Patterns of dress and diet

Issue 1: Acculturation cont…
~ Cultural Issues
~ Minority groups, immigrants, individuals from different ethnic backgrounds and those with physical handicaps may display suspiciousness, guarded or defensive behaviors resulting from perceived neglect or indifference by the majority society
~ Some ethnic groups also display culturally related behaviors which should not be confused with
~ Paranoia
~ Avoidance
~ Dependence

Issue 2: Stereotyped Gender Roles
~ Do not misdiagnose based on stereotypical gender roles
~ Females: Borderline, histrionic, dependent
~ Males: Antisocial, narcissistic
~ Personality traits are only personality disorders when inflexible, maladaptive, persistent and cause functional impairment or subjective distress
Issue 3: Differentiate from Mood Disorders with Psychotic Features
~ Paranoid, schizoid and schizotypal must not have occurred exclusively within
~ Schizophrenia
~ Bipolar
~ Depressive disorders with psychotic features
Issue 4:Personality Changes from PTSD

~ Personality changes as the result of PTSD
~ Lack of interest in social relationships
~ Solitariness
~ Affect flattening/emotional numbing
~ Irritability
~ Lack of trust/paranoia
~ Avoidance of reminders of the event

Issue 5: Addictions
~ Differential diagnosis with addictive disorders (~47%)
~ More time spent getting, using, recovering from the substance than intended
~ Irritability, grudging during withdrawal
~ Paranoia or irritability while under the influence
~ Histrionic behaviors to manipulate getting the substance
~ Inability to stop or cut down
~ Dependence on dealers
~ Failure to meet important role obligations
~ Reduction in hobbies and important activities
~ Continued use despite 2 or more problems
~ Sensitive to perceived attacks on character
~ Feelings of emptiness/low self-esteem
~ Reluctance to confide in people, doubts people’s loyalty
~ Withdrawal: Restless or irritable when not using

Issue 6: Differentiate from Autism Spectrum Disorders
~ Autism Spectrum Disorders
~ Deficits in social-emotional reciprocity
~ Deficits in nonverbal communication
~ Deficits in relationships skills; absence of interest in peers
~ Deficits in imaginative play
~ Hypo (or hyper) reactivity to stimulation
~ Insistence on sameness, inflexible adherence to routines
~ Highly restricted fixated interests

Issue 7: Differentiate from FASD
~ Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure
~ Impairment in
~ Executive functioning (planning, organization, behavioral inhibition)
~ Learning
~ Memory
~ Visual-spatial reasoning
~ Mood/behavioral regulation
~ Attention deficit
~ Impulse control
~ Social communication: Overly friendly with strangers, difficulty reading social cues or understanding social consequences
~ Daily living skills
~ Motor skills (fine and gross)

Issue 8: Alternate Conceptualizations
~ Avoidant personality disorder may be an alternate conceptualization of social anxiety/phobia
~ Antisocial and borderline personality disorder criteria can completely overlap addictive disorders, especially if the addictive behavior began in childhood (<13 years)

Paranoid Personality
~ First apparent in childhood with
~ Solitariness/poor peer relationships/social anxiety
~ Underachievement in school
~ Hypersensitivity
~ Must be present BEFORE any psychotic symptoms emerge
Paranoid Personality
~ Pervasive pattern of distrust and suspiciousness
~ Suspect of infidelity and disloyalty
~ Unforgiving / begrudging
~ Suspicious of others motives
~ Perceives and quickly reacts to attacks not apparent to others
~ Enemy or Friend
~ Confiding in others feared
~ Threats perceived in benign events or remarks
Schizoid Personality
~ Detached/flattened affect
~ Seem to lack emotion
~ React passively to adverse circumstances
~ Indifferent to criticism or praise
~ Sex of little interest
~ Tasks done solitarily
~ Absence of close friends
~ Neither desires nor enjoys close relationships
~ Takes pleasure in few activities
Schizoid Personality
~ Differential Dx
~ Paranoid Personality
~ Addiction, especially depressants/opiates
~ Persistent depressive disorder
~ Any psychotic disorders
~ Autism Spectrum Disorders

~ Magical thinking*
~ Experiences unusual perceptions*
~ Paranoid ideation
~ Eccentric behavior or odd appearance
~ Constricted or inappropriate affect
~ Unusual thinking or speech
~ Lacks close friends
~ Ideas of reference
~ Anxiety in social situations

~ Rule out psychotic and developmental disorders

Avoidant– CRINGES
~ Certainty of being liked before getting involved
~ Rejection preoccupies thoughts (social anxiety)
~ Intimacy restrained due to fear of getting shamed
~ New relationships inhibited
~ Gets around occupational activities involving others
~ Embarrassment prevents new activity
~ Self viewed as unappealing or inferior

~ Rule out body dysmporphic disorder
~ R: Reassurance required for decisions
~ E: Expressing disagreement difficult (due to fear of rejection)
~ L: Life responsibilities assumed by others
~ I: Initiating projects difficult (due to low self-confidence)
~ A: Alone (feels helpless and discomfort when alone)
~ N: Nurturance (excessive lengths to obtain)
~ C: Companionship (another relationship) sought urgently when close relationship ends
~ E: Exaggerated fears of being left to care for self

~ Differentially diagnose from separation and generalized anxiety
~ C: Conformity to law lacking
~ O: Obligations ignored
~ R: Reckless disregard for safety of self or others
~ R: Remorse lacking
~ U: Underhanded (deceitful, lies, cons others)
~ P: Planning insufficient (impulsive)
~ T: Temper (irritable and aggressive)
~ Must have symptoms of conduct disorder before age 15
~ Differentially diagnose from addictive disorders and mania/hypomania
~ A: Abandonment
~ M: Mood instability (marked reactivity of mood)
~ S: Suicidal (or self-mutilating) behavior
~ U: Unstable and intense relationships
~ I: Impulsivity (in two potentially self-destructive areas)*
~ C: Control of anger*
~ I: Identity disturbance
~ D: Dissociative (or paranoid) symptoms that are transient and stress-related
~ E: Emptiness (chronic feelings of)*
~ Differentially diagnose: Addictive disorders, depression, generalized anxiety, intermittent explosive disorder, bipolar disorder, paranoid personality disorder, antisocial and dependent personality
~ Common co-occurring: Depression, anxiety, bulimia, PTSD*
~ Prevalence may be 6% in primary care, 10% in mental health, 20% in psych hospitals
~ Nearly 50% of individuals with a BPD dx in early adulthood do not meet criteria 10 years later (but the dx persists)
~ Many adolescents and young adults display borderline characteristics as they develop identity, adjust to independence and resolve existential conflicts

~ P: Provocative (or sexually seductive) behavior
~ R: Relationships (considered more intimate than they are)
~ A: Attention (uncomfortable when not the center of attention)
~ I: Influenced easily
~ S: Style of speech (impressionistic, lacks detail)
~ E: Emotions (rapidly shifting and shallow)
~ M: Made up (physical appearance used to draw attention to self)
~ E: Emotions exaggerated (theatrical)

~ Differentially diagnose from: Fetal Alcohol Spectrum Disorder, manic/hypomanic episode, dependent personality

~ S: Special (believes he or she is special and unique)*
~ P: Preoccupied with fantasies (of unlimited success, power, brilliance, beauty, or ideal love)
~ E: Entitlement
~ C: Conceited (grandiose sense of self-importance)*
~ I: Interpersonal exploitation
~ A: Arrogant (haughty)
~ L: Lacks empathy

~ Differentially diagnose with psychotic disorders (delusions of grandeur), antisocial personality disorder, manic/hypomanic episode
Obsessive Compulsive
~ L: Loses point of activity (due to preoccupation with detail)
~ A: Ability to complete tasks (compromised by perfectionism)
~ W: Worthless objects (unable to discard)
~ F: Friendships (and leisure activities) excluded (due to a preoccupation with work)
~ I: Inflexible, scrupulous, overconscientious (on ethics, values, or morality, not accounted for by religion or culture)
~ R: Reluctant to delegate (unless others submit to exact guidelines)
~ M: Miserly (toward self and others)
~ S: Stubbornness (and rigidity)
~ Differentially diagnose with: Autism Spectrum Disorders, Social Anxiety, Schizoid Personality, OCD (true obsessions), hoarding disorder

~ Personality disorders represent a long standing and pervasive pattern of behavior which causes impairments in psychosocial functioning
~ Many people with uncontrolled mood and/or psychotic disorders may display symptoms resembling personality disorders
~ For a PD to be diagnosed, the other conditions must be brought into remission and/or the pattern of PD behavior existed before the onset of the mood or psychotic features.
~ Many treatment centers have restrictions against admission of persons with personality disorders, asserting they need a higher level of care…but then they have no where to step down to