Personality, Somatic & Sleep Disorders

Personality disorders

Definition. A personality disorder is an enduring, pervasive, inflexible pattern of inner experience and behavior that deviates from cultural norms, is stable from adolescence or early adulthood, and causes distress or impairment. The traits usually feel natural to the patient (ego-syntonic), so patients rarely seek help for the personality itself. The disorders fall into 3 clusters: A is weird, B is wild, C is worried.

Schizoid vs avoidant. Both patients are isolated, but the schizoid patient (cluster A) is content alone and has no desire for relationships, whereas the avoidant patient (cluster C) DESIRES relationships and avoids them only from fear of rejection. Schizotypal patients add odd cognition such as magical thinking.

Antisocial personality disorder requires a pervasive pattern of disregard for others' rights since age 15, age ≥18, and evidence of conduct disorder before age 15; before 18, the diagnosis is conduct disorder. It is more common in men.

Borderline personality disorder features frantic efforts to avoid abandonment, chronic emptiness, marked impulsivity, recurrent self-harm or suicidal behavior, and splitting, the classic borderline defense, in which people are seen as all-good or all-bad (idealizing, then devaluing, the therapist). First-line treatment is dialectical behavior therapy (DBT), which teaches emotion regulation and distress tolerance; medications only target specific symptoms.

Somatic symptoms and feigned illness

Somatic symptom disorder is one or more distressing somatic symptoms, which may be medically real, PLUS excessive thoughts, anxiety, or behaviors about them, typically for more than 6 months. Illness anxiety disorder (formerly hypochondriasis) is preoccupation with HAVING or acquiring a serious illness despite minimal or no symptoms, with high health anxiety for ≥6 months; patients either over-check or avoid care. Both are managed with regularly scheduled visits to a single provider and CBT, while avoiding unnecessary tests and referrals.

Conversion disorder (functional neurological symptom disorder) produces weakness, blindness, aphonia, or nonepileptic seizures that are internally inconsistent or incompatible with recognized disease, often after a psychological stressor. Positive signs include weakness that disappears with distraction and a Hoover sign; video-EEG distinguishes nonepileptic from epileptic seizures. Symptoms are involuntary, and some patients show la belle indifference.

Factitious disorder is called Munchausen syndrome when severe. Covert self-injection of insulin, for example, produces hypoglycemia with a low C-peptide. Factitious disorder imposed on another (usually a caregiver inducing illness in a child) is a form of child abuse and must be reported. Malingering is not a mental disorder but a behavior.

Dissociative and sleep disorders

Dissociative disorders often follow trauma: dissociative amnesia (with or without fugue, sudden travel with loss of identity), depersonalization/derealization disorder (feeling detached from oneself or one's surroundings with intact reality testing), and dissociative identity disorder (2 or more distinct identities, linked to severe childhood abuse). Psychotherapy is the treatment.

Chronic insomnia is difficulty initiating or maintaining sleep ≥3 nights per week for ≥3 months. First exclude sleep apnea, restless legs, depression, caffeine, alcohol, and offending drugs. First-line treatment is CBT for insomnia (CBT-I: stimulus control, sleep restriction, sleep hygiene); hypnotics are short-term adjuncts only.

Narcolepsy results from loss of hypothalamic hypocretin (orexin) neurons. It presents with excessive daytime sleepiness, cataplexy (sudden loss of muscle tone triggered by strong emotion such as laughter), hypnagogic hallucinations, and sleep paralysis. Polysomnography followed by a multiple sleep latency test shows rapid sleep onset with early REM periods. Treat with scheduled naps and modafinil; sodium oxybate helps cataplexy.

Normal grief vs depression

Grief is not a disease. Normal grief comes in waves triggered by reminders, is centered on the deceased, preserves self-worth, and still allows positive emotions; brief illusions of seeing or hearing the deceased are normal. Major depression can still be diagnosed during bereavement when its full criteria are met.

Active suicidal ideation, pervasive worthlessness, psychomotor slowing, or marked functional impairment after a loss points to MDD, which should be treated rather than dismissed as grief.