Personality Personality consists of enduring habitualpatterns of thinking, feeling, behaving,relating and determine a person’s reaction tothe two worlds, namely the innerpsychological world and the outerenvironment.
DSM-IV-TR defines personality disorders asenduring subjective experiences andbehavior that-– deviate from cultural standards– are rigidly pervasive– have an onset in adolescence or early adulthood– are stable throughout time– lead to unhappiness and impairment
Classification•Cluster A – Paranoid, Schizoid, SchizotypalWeird•Cluster B – Antisocial, Borderline, Histrionic,NarcissisticWild•Cluster C – Avoidant, Dependent, Obsessive-CompulsiveWimpy
Prevalence - 10-18%Outpatient - 30-50%Inpatient > 50%34% in alcohol abuse and anxiety disorders48-65% among recurrent suicidal gesturesEtiologyGeneticBiological factorsEnvironmental factorsPsychoanalytic theories
Psychoanalytic Factors•Sigmund Freud – personality traits areproducts of fixation at one psychosexualstage of development•Wilhelm Reich – personality arose from theparticular pattern of defense mechanisms - character armor
Defense MechanismsThe unconscious mental processes that theego uses to resolve conflictsFlexible and adaptableInflexible and rigid in personality disordersEgo-syntonic; a major reason why peoplewith these disorders are reluctant to altertheir behaviors
32 y/o male complaining of his girlfriendbeing untrustworthy Feels she is taking advantage of him Does not like her talking to friends on thephone Feels people at work dont like him Lashed out at a stranger who was laughingloudly during a funny movie
“Others are untrustworthy, and they try to take advantage of me”
Paranoid Personality Disorder SUSPECT (four of seven)Spousal infidelity suspectedUnforgivingSuspiciousPerceives attacksEnemy or friendConfiding in others fearedThreats perceived in benign events
Paranoid Personality Disorder 0.5-2.5% population, M > F, minorities,immigrants, deaf Course: Lifelong Differential Disorder: Delusional d/o,Schizophrenia, Schizoid PD, Avoidant PD Treatment: Psychotherapy Psychosis: Short term benzodiazepines andantipsychotics
38 y/o single lab tech having difficulty beinga team player. Resents having to train new assistants Describes himself as a loner who feelsawkward when forced into spending timewith others. Can spend long hours by himself playingcomputer games. Prefers being alone; not distressed by it.
“I prefer to be alone; my world is completely empty.”
Schizoid Personality Disorder DISTANT (four of seven)Detached (flat) affectIndifferent to criticism or praiseSexual experiences of little interestTasks performed solitarilyAbsence of close friendsNeither desires nor enjoys close relationsTakes pleasure in few activites
Schizoid Personality Disorder 1-7.5% ;Males > Females 2:1 Higher incidence of psychotic disorder in relatives Onset in early childhood and remains throughout life Differential Diagnosis: Schizophrenia, Paranoid PD,OCPD, Avoidant PD Treatment: Supportive, Insight- oriented andsometimes group therapy No pharmacotherapy
19 y/o college student presenting with long-standing worry of losing height. Patient appeared disheveled and did notmake eye contact. Frequently taps his nose to make a point. Doctor unable to establish rapport. Patient made some comments of a paranoidnature with sexual content.
“Id like to have friends but its hard, because people find me pretty strange.”
Schizotypal Personality Disorder ME PECULIAR (five of ten)Magical thinking or odd beliefsExperiences unusual perceptionsParanoid ideationEccentric behavior or appearanceConstricted (or inappropriate) affectUnusual thinking and speechLacks close friendsIdeas of referenceAnxiety in social situationsRule out psychotic disorder
Schizotypal Personality Disorder 3% , males> females, biological relatives ofschizophrenics Prognosis is guarded DD: Paranoid PD, Schizoid PD, Borderline PD,Avoidant PD, Schizophrenia Treatment: supportive therapy with social skillstraining Pharmacotherapy for brief periods of psychoticdecompensation
19 y/o male, comes in after encouragementfrom mother Appears intelligent, charming and funny Admits to several arrests for robbery, claimsnoble intentions Story does not pan out Extensive drug trafficking Has been stealing from mother No remorse
“I love to take advantage of people, and I never feel bad about it.”
Antisocial Personality Disorder CORRUPT (three of seven)Conformity to law is lackingObligations ignoredReckless disregard for safety of self or othersRemorse lackingUnderhandedPlanning insufficient (impulsive)Temper
Antisocial Personality Disorder Prevalence: 3% M; <1% F 5 times more common in first degree relatives 75% of poor urban prisons Conduct disorder<15; comorbid ADHD, sub abuse DD:Borderline PD, Narcissistic PD, Bipolar disorder,Psychotic violence Very difficult to treat. Confined settings with external constraints BT with a strong emphasis on legal sanctions Pharmacotherapy for dangerous behavior
45 y/o white female with a turbulent course in theclinic Has made suicide attempts in the clinic Abnormally strong attachment to previous resident Current resident feels disheartened, thinking theycan never match up to standards Does not have children, therefore collects dolls Requires weekly sessions to prevent destabilization
“I need people desperately, and fall apart completely when they reject me.”
Borderline Personality Disorder I DESPAIRRIdentity disturbanceDisordered, unstable affectEmptiness- chronic feelingSuicidal behavior, gestures, or threatsParanoid ideation- transient, stress relatedAbandonment- tries to avoidImpulsivityRage, inappropriate, intenseRelationships- unstable, intense, extreme
Borderline Personality Disorder Prevalence:2-3% of population; 2:1 F:M ratio Increased prevalence of mood disorders in familymembers; mothers of patients also have BPD Diagnosed before 40 years, variable course DD: paranoid PD, histrionic PD, bipolar disease Treatment: Psychotherapy- exploratory, insight-oriented, supportive, CBT, DBT Medications for impulsivity, lability, psychosis, moodsymptoms Be aware of Countertransference!
31 year old WF discloses to her therapist that sheloved to party in college Proud of the fact that she once slept with 12different men at a party, including her best friends boyfriend. Responds strongly to positive comments about herappearance. Sometimes vague and shallow with emotions. Easily influenced by TV, magazines and friends.
“Im an emotional and sexually charming person, and I need to be the center of attention!”
Histrionic Personality Disorder PRAISE ME (five of eight)Provocative behavior•Relationships (considered more intimate than they are)•Attention (likes to be center of)•Influenced easily•Style of speech (impressionistic)•Emotions (rapidly shifting, shallow)•Made up•Emotions exaggerated•
Histrionic Personality Disorder Prevalence: 2-3%, F>M Course is variable; comorbid somatization,dissociative, sexual and mood disorders. DD: Borderline PD, narcissistic PD, dependent PD,Somatization Individual psychodynamic psychotherapy withemotional clarification Benzos for transient emotional outbursts and anti-psychotics for dissociation and psychosis
20 y/o male seen in clinic with impotence States that he agreed to have sex with aplatonic friend; extremely anxious aboutinability to perform Hates his job, they dont know what theyredoing Feels that his friends are petty, dating prettybut stupid women Three years of therapy, never completes it
“Im talented and special, and I get angry and depressed when people dont recognize how great I am!”
Narcissistic Personality Disorder SPEEECIAL (five of nine)Special•Preoccupied with fantasies of success and power•Envious•Entitlement•Excessive admiration needed•Conceited•Interpersonal exploitation•Arrogant•Lacks empathy•
Narcissistic Personality Disorder Prevalence:1%; 2-15% of clinical population Co-morbid mood disorders; severe mid-life crisis. DD: Borderline PD, Histrionic PD, Anti-social PD Treatment : Individual psychodynamicpsychotherapy Insight-oriented psychotherapy Pharmacotherapy for depression and mood swings
35 year old black male presents to unit after asuicide attempt Patient is in love with his neighbor of 10 years Tells the psychiatrist that he would attempt suicideagain if she refused a date Admits to being shy Wants to be married and have children, and feelssad that this may never happen Often puts himself down during the interview
“Im really afraid of what people will think of me, so I avoid making new friends.”
Avoidant Personality Disorder CRINGES (four of seven)Certainty of being liked requiredRejection -preoccupied withIntimate relationships avoidedNew relationships avoidedGets around interpersonal contactEmbarrassment prevents new activitiesSelf viewed as inept, inferior
Avoidant Personality Disorder Prevalence:1-10%; temperament and disfiguringphysical illnesses are predisposing factors, M=F Co-morbid mood d/o, anxiety d/o and social phobia DD: Schizoid PD, Dependent PD, Social phobia Course: Are able to function, marry and raisefamilies as long as the environment is safe CBT Anxiolytics, MAOIs and SSRIs for anxiety anddepression
55 year old woman,married since she was17, because she didn’t want to be alone• Husband takes care of all the finances, andgives her a weekly allowance Worries excessively about making mistakesat her job and doesn’t want to be left aloneat work Worried about teenage daughter who is incollege- doesnt care anymore.
“ Im passive and dependent on others, and I go far out of my way to please those who are important to me.”
Dependent Personality Disorder RELIANCE (five of eight)Reassurance requiredExpressing disagreement difficultLife responsibilities assumed by othersInitiating projects difficultAlone (feels helpless when alone)Nurturance (goes to lengths to get support)Companionship sought urgentlyExaggerated fears of being left to care for self
Dependent Personality Disorder Prevalence - 2.5% , F>M ,increased incidence inchildhood separation anxiety DD: Avoidant PD, Borderline PD, Agoraphobia Course: co-morbid dysthymia, MDD, alcohol abuse;victims of emotional and physical abuse Treatment: Respond to individual psychotherapy,group therapy with stress on cognitive techniques,assertive training and social skills training Pharmacotherapy: Benzos and SSRIs
41 y/o grocery store manager who describesherself as a micromanager who likes to do thingsproperly Has trouble with employees because she constantlyquadruple-checks everything they do Despite her insistence on perfection, her store isnot doing well Divorced, because I had too much to do, I couldnttake care of him on top of it Never has time for fun
“Im a perfectionist, I keep lists, drive myself hard, and Im very serious about life.”
Obsessive-Compulsive Personality Disorder LAW FIRMS (four of eight)Loses point of activityAbility to complete tasks compromisedWorthless objects (unable to discard)Friendships excluded (preoccupied with work)InflexibleReluctant to delegateMiserlyStubborn
Obsessive-Compulsive Personality disorder M>F, first degree relatives DD: Obsessive-Compulsive disorder,Narcissistic PD Course: Variable, few intimate long termrelationships, may mellow with age. Depression, ETOH/ somatoform disorders Treatment: Patients often seek treatment ontheir own Group therapy , Benzos for anxiety
Personality Disorder NOS Persistent personality dysfunction that doesnot meet full criteria for a single PD, OR meetscriteria for Appendix -B of DSM-IV-TRPassive aggressive PD• Passive resistance to authority figures and toany request for adequate performance Depressive PD Pervasive pessimism, anhedonia, mirthlessness