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Personality disorder, as defined in the Diagnostic and Statistical Manual of the American Psychiatric Association, Fourth Edition, Text Revision (DSM-IV-TR), is an enduring pattern of inner experience and behavior that differs markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment

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  1. 1. PERSONALITY DISORDERS Windsor University School of Medicine Psychiatry Rotation Consultant Psychiatrist – Dr. Sharon Halliday Presentation by:OLADAPO SAMSON OLUWABUKOLA TH
  2. 2. Definition of terms Personality Disorders can be defined broadly as inflexible and maladaptive patterns of behaviour. They are pervasive, persistent, inflexible, maladaptive patterns of behaviour that deviate from expected cultural norms. They cause significant distress or functional impairment. Diagnosis is clinical. Treatment is with psychotherapy and sometimes drug therapy. Personality disorder, as defined in the Diagnostic and Statistical Manual of the American Psychiatric Association, Fourth Edition, Text Revision (DSM-IV- TR), is an enduring pattern of inner experience and behavior that differs markedly from the expectations of the individuals culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. Personality disorders are a long-standing and maladaptive pattern of perceiving and responding to other people and to stressful circumstances.
  3. 3. An Overview of HumanPersonality! Personality is the combination of thoughts, emotions and behaviors that makes you unique. Its the way you view, understand and relate to the outside world, as well as how you see yourself. Personality forms during childhood, shaped through an interaction of two factors:  Inherited tendencies, or your genes. These are aspects of your personality passed on to you by your parents, such as shyness or having a happy outlook. This is sometimes called your temperament. Its the "nature" part of the nature vs. nurture debate.  Environment, or your life situations. This is the surroundings you grew up in, events that occurred, and relationships with family members and others. It includes such things as the type of parenting you had, whether loving or abusive. This is the "nurture" part of the nature vs. nurture
  4. 4. An Overview of HumanPersonality!
  6. 6. Personality Development &Theories Personality development has been a major topic of interest for some of the most prominent thinkers in psychology and also of great concern for psychiatrist in that understanding how and why we become what we are is one of the basic core principle and tools used in psychiatry for diagnosis. Our personalities make us unique. The following theories focus on various aspects of personality development, including cognitive, social and moral development.  Piaget’s Stages of Cognitive Development  Freud’s Stages of Psychosexual Development  Freud’s Structural Model of Personality  Erikson’s Stages of Psychosocial Development  Kohlberg’s Stages of Moral Development
  7. 7. Piaget’s Stages of Cognitive Development While many aspects of his theory have not stood the test of time, the central idea remains important today: children think differently than adults. Albert Einstein called Piagets discovery "so simple only a genius could have thought of it." Piagets stage theory describes the cognitive development of children. Cognitive development involves changes in cognitive process and abilities. In Piagets view, early cognitive development involves processes based upon actions and later progresses into changes in mental operations. Key Concepts  Schemas - A schema describes both the mental and physical actions involved in understanding and knowing. Schemas are categories of knowledge that help us to interpret and understand the world.  In Piagets view, a schema includes both a category of knowledge and the process of obtaining that knowledge. As experiences happen, this new information is used to modify, add to, or change previously existing schemas.  For example, a child may have a schema about a type of animal, such as a dog. If the childs sole experience has been with small dogs, a child might believe that all dogs are small, furry, and have four legs. Suppose then that the child encounters a very large dog. The child will take in this new information, modifying the previously existing schema to include this new information.
  8. 8. Piaget’s Stages of CognitiveDevelopment  Assimilation - The process of taking in new information into our previously existing schemas is known as assimilation. The process is somewhat subjective, because we tend to modify experience or information somewhat to fit in with our preexisting beliefs. In the example above, seeing a dog and labeling it "dog" is an example of assimilating the animal into the childs dog schema.  Accommodation - Another part of adaptation involves changing or altering our existing schemas in light of new information, a process known as accommodation. Accommodation involves altering existing schemas, or ideas, as a result of new information or new experiences. New schemas may also be developed during this process. Equilibration - Piaget believed that all children try to strike a balance between assimilation and accommodation, which is achieved through a mechanism Piaget called equilibration. As children progress through the stages of cognitive development, it is important to maintain a balance between applying previous knowledge (assimilation) and changing behavior to account for new knowledge (accommodation). Equilibration helps explain how children are able to move from
  9. 9. Freud’s Stages of PsychosexualDevelopment  Freud suggested that personality develops in stages that are related to specific erogenous zones. Failure to successfully complete these stages, he suggested, would lead to personality problems in adulthood.  Freuds theory of psychosexual development is one of the best known, but also one of the most controversial. Freud believed that personality develops through a series of childhood stages during which the pleasure-seeking energies of the id become focused on certain erogenous areas. This psychosexual energy, or libido, was described as the driving force behind behavior.  If these psychosexual stages are completed successfully, the result is a healthy personality. If certain issues are not resolved at the appropriate stage, fixation can occur. A fixation is a persistent focus on an earlier psychosexual stage. Until this conflict is resolved, the individual will remain "stuck" in this stage. For example, a person who is fixated at the oral stage may be over-dependent on others and may seek oral stimulation through smoking, drinking,
  10. 10. Freud’s Stages of PsychosexualDevelopmentSTAG EROGENOU AGE REMARKS E S ZONE RANG E Oral Mouth Birth – •Rooting and sucking reflex is especially important •The primary conflict at this stage is the weaning process--Stage 1 year the child must become less dependent upon caretakers. If fixation occurs at this stage, Freud believed the individual would have issues with dependency or aggression. Oral fixation can result in problems with drinking, eating, smoking or nail biting.Anal Bowel and 1–3 •Primary focus of the libido was on controlling bladder and bowel movements.Stage Bladder years •The major conflict at this stage is toilet training--the child control has to learn to control his or her bodily needs. Developing this control leads to a sense of accomplishment and independence. •Freud believed that positive experiences during this stage served as the basis for people to become competent, productive and creative adults. •If parents take an approach that is too lenient, Freud suggested that an anal-expulsive personality could develop in which the individual has a messy, wasteful or destructive personality. •If parents are too strict or begin toilet training too early, Freud believed that an anal-retentive personality develops
  11. 11. Freud’s Stages of PsychosexualDevelopmentSTAG EROGENOU AGE REMARKS E S ZONE RANG EPhallic Genitals 3–6 •At this age, children also begin to discover the differences between males and females.Stage years •Eventually, the child begins to identify with the same-sex parent as a means of vicariously possessing the other parent.Latent Sexual 6 to •The libido interests are suppressed. The development ofstage feelings are puberty the ego and superego contribute to this period of calm. •The stage begins around the time that children enter into inactive school and become more concerned with peer relationships, hobbies and other interests. •The latent period is a time of exploration in which the sexual energy is still present, but it is directed into other areas such as intellectual pursuits and social interactions. This stage is important in the development of social and communication skills and self-confidence.Genital Maturing Puberty •The individual develops a strong sexual interest in the opposite sex.Stage sexual to •Where in earlier stages the focus was solely on individual interest death needs, interest in the welfare of others grows during this stage. •If the other stages have been completed successfully,
  12. 12. Freud’s Stages of PsychosexualDevelopment  Evaluating Freud’s Psychosexual Stage Theory  The theory is focused almost entirely on male development with little mention of female psychosexual development.  His theories are difficult to test scientifically. Concepts such as the libido are impossible to measure, and therefore cannot be tested. The research that has been conducted tends to discredit Freuds theory.  Future predictions are too vague. How can we know that a current behavior was caused specifically by a childhood experience? The length of time between the cause and the effect is too long to assume that there is a relationship between the two variables.  Freuds theory is based upon case studies and not empirical research. Also, Freud based his theory on the recollections of his adult patients, not on actual
  13. 13. Freud’s Structural Model ofPersonality According to Sigmund Freuds psychoanalytic theory of personality, personality is composed of three elements. These three elements of personality--known as the id, the ego and the superego – work together to create complex human behaviors. The Id  The id is the only component of personality that is present from birth. This aspect of personality is entirely unconscious and includes of the instinctive and primitive behaviors. According to Freud, the id is the source of all psychic energy, making it the primary component of personality.  The id is driven by the pleasure principle, which strives for immediate gratification of all desires, wants, and needs. If these needs are not satisfied immediately, the result is a state anxiety or tension. For example, an increase in hunger or thirst should produce an immediate attempt to eat or drink. The id is very important early in life, because it ensures that an infants needs are met. If the infant is hungry or uncomfortable, he or she will cry until the demands of the id are met.  However, immediately satisfying these needs is not always realistic or even possible. If we were ruled entirely by the pleasure principle, we might find ourselves grabbing things we want out of other peoples hands to satisfy our own cravings. This sort of behavior would be both disruptive and socially unacceptable. According to Freud, the id tries to resolve the tension created by the pleasure principle through the primary
  14. 14. Freud’s Structural Model ofPersonality The Ego  The ego is the component of personality that is responsible for dealing with reality. According to Freud, the ego develops from the id and ensures that the impulses of the id can be expressed in a manner acceptable in the real world. The ego functions in both the conscious, preconscious, and unconscious mind.  The ego operates based on the reality principle, which strives to satisfy the ids desires in realistic and socially appropriate ways. The reality principle weighs the costs and benefits of an action before deciding to act upon or abandon impulses. In many cases, the ids impulses can be satisfied through a process of delayed gratification--the ego will eventually allow the behavior, but only in the appropriate time and place.  The ego also discharges tension created by unmet impulses through the secondary process, in which the ego tries to find an object in the real world that matches the mental image created by the ids primary process. The Superego  The last component of personality to develop is the superego. The superego is the aspect of personality that holds all of our internalized moral standards and ideals that we acquire from both parents and society--our sense of right and wrong. The superego provides guidelines for making judgments.  According to Freud, the superego begins to emerge at around age five.
  15. 15. Freud’s Structural Model ofPersonality  There are two parts of the superego:  The ego ideal includes the rules and standards for good behaviors. These behaviors include those which are approved of by parental and other authority figures. Obeying these rules leads to feelings of pride, value and accomplishment.  The conscience includes information about things that are viewed as bad by parents and society. These behaviors are often forbidden and lead to bad consequences, punishments or feelings of guilt and remorse.  The superego acts to perfect and civilize our behavior. It works to suppress all unacceptable urges of the id and struggles to make the ego act upon idealistic standards rather that upon realistic principles. The superego is present in the conscious, preconscious and unconscious. The Interaction of the Id, Ego and Superego  With so many competing forces, it is easy to see how conflict might arise between the id, ego and superego. Freud used the term ego strength to refer to the egos ability to function despite these dueling forces. A person with good ego strength is able to effectively manage these pressures, while those with too much or too little ego strength can become too unyielding or too disrupting.  According to Freud, the key to a healthy personality is a balance between the id, the ego, and the superego.
  16. 16. Erikson’s Stages of PsychosocialDevelopment Eriksons theory describes the impact of social experience across the whole lifespan. One of the main elements of Eriksons psychosocial stage theory is the development of ego identity. Ego identity is the conscious sense of self that we develop through social interaction. According to Erikson, our ego identity is constantly changing due to new experiences and information we acquire in our daily interactions with others. In addition to ego identity, Erikson also believed that a sense of competence motivates behaviors and actions. Each stage in Eriksons theory is concerned with becoming competent in an area of life. If the stage is handled well, the person will feel a sense of mastery, which is sometimes referred to as ego strength or ego quality. If the stage is managed poorly, the person will emerge with a sense of inadequacy. In each stage, Erikson believed people experience a conflict that serves as a turning point in development. In Eriksons view, these conflicts are centered on either developing a psychological quality or failing to develop that quality. During these times, the potential for personal growth is high, but so is the potential for failure.
  17. 17. Erikson’s Stages of PsychosocialDevelopment Psychosocial Stage 1 - Trust vs. Mistrust  The first stage of Eriksons theory of psychosocial development occurs between birth and one year of age and is the most fundamental stage in life.2  Because an infant is utterly dependent, the development of trust is based on the dependability and quality of the childs caregivers.  If a child successfully develops trust, he or she will feel safe and secure in the world. Caregivers who are inconsistent, emotionally unavailable, or rejecting contribute to feelings of mistrust in the children they care for. Failure to develop trust will result in fear and a belief that the world is inconsistent and unpredictable. Psychosocial Stage 2 - Autonomy vs. Shame and Doubt  The second stage of Eriksons theory of psychosocial development takes place during early childhood and is focused on children developing a greater sense of personal control.  Like Freud, Erikson believed that toilet training was a vital part of this process. However, Eriksons reasoning was quite different then that of Freuds. Erikson believe that learning to control ones bodily functions leads to a feeling of control and a sense of independence.  Other important events include gaining more control over food choices, toy preferences, and clothing selection.  Children who successfully complete this stage feel secure and confident, while those who do not are left with a sense of inadequacy and self-doubt.
  18. 18. Erikson’s Stages of PsychosocialDevelopment Psychosocial Stage 3 - Initiative vs. Guilt  During the preschool years, children begin to assert their power and control over the world through directing play and other social interactions.  Children who are successful at this stage feel capable and able to lead others. Those who fail to acquire these skills are left with a sense of guilt, self-doubt, and lack of initiative.3 Psychosocial Stage 4 - Industry vs. Inferiority  This stage covers the early school years from approximately age 5 to 11.  Through social interactions, children begin to develop a sense of pride in their accomplishments and abilities.  Children who are encouraged and commended by parents and teachers develop a feeling of competence and belief in their skills. Those who receive little or no encouragement from parents, teachers, or peers will doubt their abilities to be successful. Psychosocial Stage 5 - Identity vs. Confusion  During adolescence, children explore their independence and develop a sense of self.  Those who receive proper encouragement and reinforcement through personal exploration will emerge from this stage with a strong sense of self and a feeling of independence and control. Those who remain unsure of their beliefs and desires will feel insecure and confused about themselves and the future.
  19. 19. Erikson’s Stages of PsychosocialDevelopment Psychosocial Stage 6 - Intimacy vs. Isolation  This stage covers the period of early adulthood when people are exploring personal relationships.  Erikson believed it was vital that people develop close, committed relationships with other people. Those who are successful at this step will form relationships that are committed and secure.  Remember that each step builds on skills learned in previous steps. Erikson believed that a strong sense of personal identity was important for developing intimate relationships. Studies have demonstrated that those with a poor sense of self tend to have less committed relationships and are more likely to suffer emotional isolation, loneliness, and depression. Psychosocial Stage 7 - Generativity vs. Stagnation  During adulthood, we continue to build our lives, focusing on our career and family.  Those who are successful during this phase will feel that they are contributing to the world by being active in their home and community. Those who fail to attain this skill will feel unproductive and uninvolved in the world. Psychosocial Stage 8 - Integrity vs. Despair  This phase occurs during old age and is focused on reflecting back on life.  Those who are unsuccessful during this stage will feel that their life has been wasted and will experience many regrets. The individual will be left with feelings of bitterness and despair.  Those who feel proud of their accomplishments will feel a sense of integrity.
  20. 20. Kohlberg’s Stages of MoralDevelopment Lawrence Kohlberg who modified and expanded upon Jean Piagets work to form a theory that explained the development of moral reasoning. Piaget described a two-stage process of moral development, while Kohlbergs theory of moral development outlined six stages within three different levels. Kohlberg extended Piagets theory, proposing that moral development is a continual process that occurs throughout the lifespan. Level 1. Preconventional Morality  Stage 1 - Obedience and Punishment – The earliest stage of moral development is especially common in young children, but adults are also capable of expressing this type of reasoning. At this stage, children see rules as fixed and absolute. Obeying the rules is important because it is a means to avoid punishment.  Stage 2 - Individualism and Exchange – At this stage of moral development, children account for individual points of view and judge actions based on how they serve individual needs. In the Heinz dilemma, children argued that the best course of action was the choice that best-served Heinz’s needs. Reciprocity is possible at this point in moral development, but only if it serves
  21. 21. Kohlberg’s Stages of MoralDevelopment Level 2. Conventional Morality  Stage 3 - Interpersonal Relationships – Often referred to as the "good boy-good girl" orientation, this stage of moral development is focused on living up to social expectations and roles. There is an emphasis on conformity, being "nice," and consideration of how choices influence relationships.  Stage 4 - Maintaining Social Order – At this stage of moral development, people begin to consider society as a whole when making judgments. The focus is on maintaining law and order by following the rules, doing one’s duty and respecting authority. Level 3. Postconventional Morality  Stage 5 - Social Contract and Individual Rights – At this stage, people begin to account for the differing values, opinions and beliefs of other people. Rules of law are important for maintaining a society, but members of the society should agree upon these standards.  Stage 6 - Universal Principles – Kolhberg’s final level of moral reasoning is based upon universal ethical principles and abstract reasoning. At this stage, people follow these internalized principles of justice, even if they conflict with laws
  22. 22. Kohlberg’s Stages of MoralDevelopment Criticisms of Kohlbergs Theory of Moral Development:  Does moral reasoning necessarily lead to moral behavior? Kohlbergs theory is concerned with moral thinking, but there is a big difference between knowing what we ought to do versus our actual actions.  Is justice the only aspect of moral reasoning we should consider? Critics have pointed out that Kohlbergs theory of moral development overemphasizes the concept as justice when making moral choices. Factors such as compassion, caring and other interpersonal feelings may play an important part in moral reasoning.  Does Kohlbergs theory overemphasize Western philosophy? Individualistic cultures emphasize personal rights while collectivist cultures stress the importance of society and community. Eastern cultures may have
  23. 23. Overview of Clusters Basically, Personality Disorders, PDs, are things people do that probably annoy everybody else but as far as we are concern, we are okay and its everyone else who have the problem. Thinking about this in the psychiatric terms, PDs patients tend to be egodystonic, meaning they are okay with themselves and happy with the way they are. CLUSTERS  A- Odd eccentric type includes paranoid, schizoid and schizotypal)  B – Dramatic emotional type includes borderline, narcissistic, histrionic and antisocial  C - Anxious – Fearful type includes avoidance, obsessive- compulsive and dependent.  Not specified – Depressive, passive-aggressive, Sadistic and Self-defeating.
  24. 24. Overview of Clusters
  25. 25. Incidence Because the DSM-IV-TR criteria are so bound to North American cultural definitions, epidemiologic data about personality disorders in other countries are notoriously unreliable, but nonetheless the incidence ranges between 5- 10% of the general population. Taking the United State as a case study, personality disorders affect 10-15% of the adult US population. Individuals may have more than one personality disorder. The following are prevalences for specific personality disorders in the general population:  Paranoid personality disorder - 0.5-2.5%  Schizotypal (Schizoid) personality disorder - 3%  Antisocial personality disorder - 3% of men, 1% of women  Borderline personality disorder - 2%  Histrionic personality disorder - 2-3%  Narcissistic personality disorder - Less than 1%  Avoidant personality disorder - 0.5-1%  Obsessive-compulsive personality disorder - 1%
  26. 26. Epidemiological Facts Race: No differences in prevalence across the races have been noted. Sex  Cluster A: Schizoid personality disorder is slightly more common in males than in females.  Cluster B: Antisocial personality disorder is 3 times more prevalent in men than in women. Borderline personality disorder is 3 times more common in women than in men. Of patients with narcissistic personality disorder, 50-75% are male.  Cluster C: Obsessive-compulsive personality disorder is diagnosed twice as often in men than in women. Age: Personality disorders generally should not be diagnosed in children and adolescents because personality development is not complete and symptomatic traits may not persist into adulthood. Therefore, the rule of thumb is that personality diagnosis cannot be made until the person is at least 18 years of age. Because the criteria for diagnosis of personality disorders are closely related to behaviors of young and middle adulthood, DSM-IV-TR diagnoses of personality disorders are notoriously unreliable in the elderly population. Mortality/Morbidity: Risk of death is usually related to conditions or behaviors resulting from the disorder, such as suicide, substance abuse, or injuries from motor vehicle accidents and fighting.
  27. 27. Risk Factors Nobody, actually, knows what causes personality disorders – are we born this way or do we learn to become this way; chances are its going to be a little bit of both. Thus risk factors or more likely the predisposing factors to PDs include:  Innate temperamental difficulties  Adverse environmental events  Personality disorders in parents – something we learn from patents and we watch them react to things and that’s how we become as well.  Low socioeconomic status  Verbal, physical or sexual abuse during childhood  Neglect during childhood  An unstable or chaotic family life during childhood  Being diagnosed with childhood conduct disorder  Loss of parents through death or traumatic divorce during childhood Personality disorders often begin in childhood and last through adulthood. Theres reluctance to diagnose personality disorders in a child, though, because the patterns of behavior and thinking
  28. 28. Etiology Etiology is not clearly known, but several studies and theories concerning the etiology include:  Personality disorders are thought to result from a bad interface, so to speak, between a childs temperament and character on one hand and his or her family environment on the other.  Personality disorders are thought to be caused by a combination of genetic and environmental influences. You may have a genetic vulnerability to developing a personality disorder and your life situation may trigger the actual development of a personality disorder.  In the past, some believed that people with personality disorders were just lazy or even evil. But new research has begun to explore such potential causes as genetics, parenting and peer influences:  Genetic  Psychological  Social
  29. 29. Etiology – Genetic Genetics. Researchers are beginning to identify some possible genetic factors behind personality disorders. Some have been able to identify a malfunctioning gene that may be a factor in obsessive-compulsive disorder while others are exploring genetic links to aggression, anxiety and fear – traits that can play a role in personality disorders.
  30. 30. Etiology – Psychological High reactivity. Sensitivity to light, noise, texture and other stimuli may also play a role.  Overly sensitive children, who have what researchers call “high reactivity,” are more likely to develop shy, timid or anxious personalities.  However, high reactivity’s role is still far from clear- cut. Twenty percent of infants are highly reactive, but less than 10 percent go on to develop social phobias.
  31. 31. Etiology – Social Verbal abuse. Even verbal abuse can have an impact. In a study of 793 mothers and children, researchers asked mothers if they had screamed at their children, told them they didn’t love them or threatened to send them away. Children who had experienced such verbal abuse were three times as likely as other children to have borderline, narcissistic, obsessive-compulsive or paranoid personality disorders in adulthood. Peers. Certain factors can help prevent children from developing personality disorders.  Even a single strong relationship with a relative, teacher or friend can offset negative influences, say psychologists.
  32. 32. Etiology – Social Childhood trauma. Findings from one of the largest studies of personality disorders, the Collaborative Longitudinal Personality Disorders Study, offer clues about the role of childhood experiences.  One study found a link between the number and type of childhood traumas and the development of personality disorders. People with borderline personality disorder, for example, had especially high rates of childhood sexual trauma and this also justifies the prevalence of borderline personality disorder among females.
  33. 33. Etiology - Social Other factors that have been cited as affecting childrens personality development are the mass media and social or group hysteria, particularly after the events of September 11, 2001. Cases of so-called mass sociogenic illness have been identified, in which a group of children began to vomit or have other physical symptoms brought on in response to an imaginary threat. In two such cases, the children were reacting to the suggestion that toxic fumes were spreading through their school. Some authors believe that overly frequent or age-inappropriate discussions of terrorist attacks or bioterrorism may make children more susceptible to sociogenic illness as well as other
  34. 34. Pathogenesis Abnormalities may be seen in the frontal, temporal, and parietal lobes. These abnormalities may be caused by perinatal injury, encephalitis, trauma, or genetics. Personality disorders are also seen with diminished monoamine oxidase (MAO) and serotonin levels. Relationships of anatomy, receptors, and neurotransmitters to personality disorders are purely speculative at this point. Frequently, a history of psychiatric disorders is present. Developmental abnormalities secondary to abuse or incest may be present. The 5-factor model has been used to describe the different accepted types of personality disorders. Most current research suggests that personality disorders may be differentiated by their interactions among the 5 dimensions rather than differences on any single dimension. In general, patients with personality disorders have wide-ranging problems in social relationships and mood regulation. These problems have usually been present throughout adult life. These patients patterns of perception, thought, and response are fixed and inflexible, although their behavior is often unpredictable. These patterns markedly deviate from their specific cultures expectations. To meet the DSM-IV threshold for clinical diagnosis, the pattern must result in clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  35. 35. Pathophysiology The origin of personality disorders is a matter of considerable controversy. Traditional thinking holds that these maladaptive patterns are the result of dysfunctional early environments that prevent the evolution of adaptive patterns of perception, response, and defense. A body of data points toward genetic and psychobiologic contributions to the symptomology of these disorders; however, the inconsistency of the data prevents authorities from drawing definite conclusions.
  36. 36. Clinical Features General symptoms of a personality disorder  Frequent mood swings  Stormy relationships  Social isolation  Angry outbursts  Suspicion and mistrust of others  Difficulty making friends  A need for instant gratification  Poor impulse control  Alcohol or substance abuse
  37. 37. Clinical features - Clusters The two major systems of classification, the ICD and DSM, have deliberately merged their diagnoses to some extent, but there remain differences. For example, ICD-10 does not include narcissistic personality disorder as a distinct category, while DSM-IV does not include enduring personality change after catastrophic experience or after psychiatric illness. ICD-10 classifies the DSM-IV schizotypal personality disorder as a form of schizophrenia rather than as a personality disorder. DSM-IV places personality disorders on a separate axis to mental disorders, while the ICD does not use a multiaxial system. There are accepted diagnostic issues and controversies with regard to either section, in terms of distinguishing personality disorders as a category from other types of mental disorder or from general personality Bfunctioning, or distinguishing particular CLUSTER A CLUSTER CLUSTER C NOT SPECIFIED personality disorder categories from each other. (ODD) (DRAMATIC) (ANXIOUS)Paranoid Borderline Avoidant DepressiveSchizoid Narcissistic Dependent Passive-Schizotypal Histrionic Obsessive- aggressive Antisocial compulsive Sadistic Self-defeating Cyclothymic
  38. 38. CLUSTER A
  39. 39. CLUSTER A – Odd Eccentric Type Includes the paranoid, schizoid and schizotypal personality disorders. Affected individuals use the defense mechanism of projection and fantasy and may have a tendency toward psychotic thinking.  Projection involves attributing to another person the thoughts or feelings of one’s own that are unacceptable  Fantasy is the creation of an imaginary life with which the patient deals with loneliness. A fantasy can be quite elaborate and extensive. Paranoia is a feeling of being persecuted or treated unfairly by others. Paranoid patients may feel that others are talking about or making fun of them. Biologically, patients with cluster A personality disorders may have a vulnerability to cognitive disorganization when stressed. These disorders do not occur exclusively during the course of schizophrenia, which is a mood disorder
  40. 40. Cluster A – Paranoid Individuals with this disorder display pervasive distrust and suspiciousness. Common beliefs include the following:  Others are exploiting or deceiving the person.  Friends and associates are untrustworthy.  Information confided to others will be used maliciously.  There is hidden meaning in remarks or events others perceive as benign.  The spouse or partner is PersonalityMajor traits of the Paranoid unfaithful. Disorder, PPD, include: •Expectations of being harmed or exploited without a sufficient bias •Preoccupation with unjustified doubts •Reluctance to confide in others •Persistently bearing grudges •Perceiving attacks on character or reputation not apparent to others. •Never give up personal information out of fear •Hallucinate that people are chasing them or attacking them which sometimes leads to a violent reaction •They cannot see that they are wrong with their thoughts •Can be hostile and prone to arguments
  41. 41. Cluster A - Paranoid The same as most personality disorders, people with PPD don’t realize they have a problem and are not likely to seek professional help unless other issues appear. The prevalence of paranoid personality disorder is unknown. People tend to group themselves in esoteric religions and pseudoscientific and quasipolitical groups. Groups of paranoid individuals who set themselves apart and see others as “the enemy” tend to provoke negative reactions from the outside, which reinforces their paranoid views. Causes: A genetic contribution to paranoid traits and a possible genetic link between this
  42. 42. Cluster A - Paranoid Summarily, Paranoid personality involves coldness and distancing in relationships, with a need for control and a tendency toward jealousy if attachments are formed. Affected people are often secretive and untrusting. They tend to be suspicious of changes and frequently find hostile and malevolent motives behind other people’s acts. Often, these hostile motives represent projections of their own hostilities onto others. Their reactions sometimes surprise or scare others. They then use the resulting anger of or rejection by others (i.e., projective identification) to justify their original feelings. Paranoid people tend to feel a sense of righteous indignation and often take legal action against others. These people may be highly efficient and conscientious, although they usually need to work in relative isolation. This disorder must be differentiated from paranoid schizophrenia.
  43. 43. Cluster A - Schizoid This type of personality disorder is uncommon in clinical settings. A person with this disorder is markedly detached from others and has little desire for close relationships. This persons life is marked by little pleasure in activities and tends to be anhedonic. People with this disorder appear indifferent to the praise or criticism of others and often seem cold or aloof. It can be described as pervasive pattern of detachment from social relationships and restriction of emotion in interpersonal settings that begins by early adulthood. Characterized by the following major traits:  Neither desiring nor enjoying close relationships; choosing solitary activities  Little interest in sex  Indifference to praise or criticism  Emotional frigidity
  44. 44. Cluster A - Schizoid Because patients with schizoid personality disorder rarely seek treatment, the prevalence of this condition is unknown. Schizoid personality disorder is present in a variety of contexts. The diagnosis can be made when at least four of following is present:  No desire or enjoyment of close relationships, including being part of a family  Choice of solitary activities (almost always)  Little, if any, interest in having sexual experiences with another person  Enjoyment of few, if any, activities  Lack of close friends or confidants other than first-degree relatives  Apparent indifference to the praise or criticism of others  Emotional coldness, detachment, or flattened affect
  45. 45. Cluster A - Schizoid Summarily, Schizoid personality is characterized by introversion, social withdrawal, isolation, and emotional coldness and distancing. Affected individuals are often absorbed in their own thoughts and feelings and fear closeness and intimacy with other people. They are reticent, are given to daydreaming, and prefer theoretical speculation to practical action.
  46. 46. Cluster A – Schizotypal Several studies indicate that 3% of the population has this disorder. The problems posed by treating patients with schizotypal personality disorder and a medical or surgical illness are similar to those encountered with schizoid patients. Illness threatens their isolation. The central features of this disorder are pervasive patterns of “strange” or “odd” thought, perception, and behavior. These peculiarities are not so severe that they can be termed schizophrenic, and there is no history of psychotic episodes. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships is indicative. People with this disorder exhibit marked eccentricities of thought, perception, and behavior. Cognitive or perceptual distortions also occur.
  47. 47. Cluster A – Schizotypal Schizotypal personality disorder is indicated by the presence of at least five of the following:  Ideas of reference (i.e., believing that public messages are directed personally at them)  Odd beliefs or magical thinking that influence behavior and are inconsistent with sub-cultural norms (e.g., belief in superstitions, clairvoyance, telepathy, or “sixth sense”, in children and adolescents, bizarre fantasies or preoccupations)  Idiosyncratic perceptual experiences or bodily illusions  Odd thinking and speech (e.g., vague, circumstantial, metaphorical, over-elaborate, or stereotyped speech)  Suspiciousness or paranoid ideation  Inappropriate or constricted affect  Behavior or appearance that is odd, eccentric or peculiar  Lack of close friends or confidants other than first-degree relatives  Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.
  48. 48. Cluster A – Schizotypal Summarily, Schizotypal personality, like the schizoid personality, involves social withdrawal and emotional coldness but also includes oddities of thinking, perception, and communication, such as magical thinking, clairvoyance, idea of reference, or paranoid ideation. These oddities suggest schizophrenia but are never severe enough to meet its criteria. People with schizotypal
  49. 49. CLUSTER B
  50. 50. CLUSTER B– Dramatic EmotionalType This cluster includes histrionic, narcissistic, antisocial, and borderline personality disorders. Affected individuals tend to use certain defense mechanisms such as dissociation, denial, splitting, and acting out.  Dissociation involves the “forgetting” of unpleasant feelings and associations. It is the unconscious splitting off of some mental processes and behavior from the normal or conscious awareness of the individual. When extreme, this can lead to multiple or disorganized personalities.  Denial is closely associated with dissociation. In denial, patients refuse to acknowledge a thought, feeling, or wish but are unaware of doing so.
  51. 51. CLUSTER B– Dramatic EmotionalType  Splitting, often seen in patients with borderline personalities, occurs when these individuals view other persons as “all good” or “all bad”. Affected patients cannot experience an ambivalent relationship and cannot even be ambivalent in regard to their own self-image.  Acting out involves the actual motor expression of a thought or feeling that is intolerable to a patient, this can involve both aggressive and sexual behavior. Patients with these types of personality disorders may be biologically vulnerable to stress (i.e., a tendency to low cortical arousal causes them to easily over-stimulate) and a wide variation of autonomic and motor activities. Thus, a psychobiologic pattern may develop, which increases the potential for acting out that is not associated with any particular anxiety. Mood disorders are common and may be the chief complaint. Somatization disorder is associated with histrionic personality disorder. Patients tend to be emotionally unstable, impulsive, and intense.
  52. 52. Cluster B – Borderline
  53. 53. Cluster B – Borderline The central feature of borderline personality disorder is a pervasive pattern of unstable and intense interpersonal relationships, self-perception, and moods. Impulse control is markedly impaired. Transiently, such patients may appear psychotic because of the intensity of their distortions. Borderline personality disorder is one of the most commonly overused diagnoses in DSM-IV. Diagnostic criteria require at least 5 of the following features:  Frantic efforts to avoid expected abandonment;  Unstable and intense interpersonal relationships characterized by alternating between extremes of
  54. 54. Cluster B – Borderline Identity disturbance, that is, markedly and persistently disturbed, distorted, or unstable self-image or sense of self Impulsivity in at least 2 areas that are potentially self- damaging (e.g., sex, substance abuse, reckless driving) Recurrent suicidal behaviors or threats or self- mutilation behavior Affective instability due to a marked reactivity of mood Chronic feelings of emptiness Inappropriate and intense anger or lack of control of
  55. 55. Cluster B – Borderline This disorder may be present in 1-2 % of the population. The diagnosis is made twice as frequently in women. Of the individuals with this diagnosis 90 % also have one of other psychiatric diagnosis and 40 % have two other diagnoses. Summarily, borderline personality disorder is marked by unstable self-image, mood, behavior, and relationships. Affected people are often hypertensive; they tend to believe they were deprived of adequate care during childhood and consequently feel empty, angry, and entitled to nurturance. As a result, they relentlessly seek care and are sensitive to its perceived absence. Their relationships tend to be intense and dramatic. When feeling cared for, they appear like lonely waifs who seek help for depression, substance abuse, eating disorders, and past mistreatments.
  56. 56. Cluster B – Borderline When they fear the loss of the caring person, they frequently express inappropriate intense anger. These mod shifts are typically accompanied by extreme by extreme changes in their views of the world, themselves, and other people – e.g. from bad to good, from hated to loved. When they feel abandoned, they dissociate or become desperately impulsive. Their concept of reality is sometimes so poor that they have brief episodes of psychotic thinking, such as paranoid delusions and hallucinations. They often become self-destructive and may cut themselves (self-mutilate) or attempt suicide. They initially tend to evoke intense, nurturing responses on caretakers, but after repeated crises, vague unfounded complaints, and failure to adhere to therapeutic recommendations, they are viewed as help-rejecting complainers. Borderline personality tends to become milder or to
  57. 57. Cluster B – Narcissistic A pervasive pattern of grandiosity, need for admiration, and a lack of empathy. Characterized by self- importance, preoccupations with fantasies, belief that they are special, including a sense of entitlement and a need for excessive admiration, and extreme levels of jealousy and arrogance. Individuals have a grandiose sense of their own importance but are also extremely sensitive to criticism. They have little ability to empathize with others, and they are more concerned about appearance than substance. Narcissistic patients have a pervasive pattern of grandiosity, need for admiration, and lack of empathy that begins in early adulthood and is present in a variety of contexts. Narcissistic personality disorder is indicated by at least 5 of the following:  A grandiose sense of self-importance (e.g., exaggeration of achievements and talents, expectation for recognition as superior without commensurate achievements)
  58. 58. Cluster B – Narcissistic  Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love  Belief that she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)  Requirement for excessive admiration  A sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with her views)  Behavior that is interpersonally exploitative (i.e., takes advantage of others as a means to achieve her own ends)  Lack of empathy (i.e., unwilling to recognize or identify with the feelings and needs of others)
  59. 59. Cluster B – Narcissistic  Jealousy or belief that others are envious of her  Arrogance, demonstration of haughty behavior or attitude Summarily, Narcissistic personality involves grandiosity. Affected individuals have an exaggerated sense of superiority and expect to be treated with deference and preference. Their relationships are characterized by a need to be admired, and they are extremely sensitive to criticism, failure, or defeat. When confronted with a failure to fulfill their high opinion of themselves, they can become enraged or seriously depressed and suicidal. The often believe other people envy them. They may exploit other
  60. 60. Cluster B – Histrionic Excessive emotionality and attention-seeking behavior. Patients with histrionic personality disorder display excessive emotionality and attention-seeking behavior. They are quite dramatic and often sexually provocative or seductive. Their emotions are labile. In clinical settings, their tendency to vague and impressionistic speech is often highlighted. The disorder was formerly called “hysterical personality”, but that term was discarded because of the many meanings of the word “hysterical”. A pervasive pattern of excessive emotionality and attention seeking that begins by early adulthood and is present in a variety of contexts is characteristic. Histrionic personality disorder is indicated by at least 5 of the following:  Feeling of discomfort in situations in which she is not the center of attention  Interaction with others that is often characterized as inappropriately sexually seductive of provocative
  61. 61. Cluster B – Histrionic  Insincere affect (i.e., display of rapidly shifting and shallow expression of emotions)  Consistent use of physical appearance to draw attention to herself  Speech that is excessively impressionistic and lacking in detail  Self-dramatization, with a theatrical and exaggerated expression of emotion  Suggestibility (i.e., easily influenced by others or circumstances)  Exaggeration of importance of relationships and acquaintances The prevalence of histrionic personality disorder is not known with certainty. The condition, which is thought to be common, is diagnosed in women much more often than in men. Men who exhibit
  62. 62. Cluster B – Histrionic Summarily, Histrionic personality involves conspicuous attention seeking. Affected people are also overly conscious of appearance and are dramatic. Their expression of emotions often seems exaggerated, childish, and superficial. Still, they frequently evoke sympathetic or erotic attention from other people. Relationships are often easily established and overly sexualized but ten to be superficial and transient. Behind their seductive behaviors and their tendency to exaggerate somatic problems (i.e. hypochondria) often lie more basic wishes for dependency and
  63. 63. Cluster B – Antisocial Chronic maladaptive behavior that disregards the rights of others. Individuals with antisocial personality disorder display a pervasive pattern of disregard for and violation of the rights of others and the rules of society. Individuals have a history of continuous and chronic antisocial behavior in which the rights of others are violated.  The essential defect is one of character structure in which affected individuals are seemingly unable to control their impulses and postpone immediate gratification.  Affected individuals lack sensitivity to the feelings of others. They are egocentric, selfish, and excessively demanding, in addition, they are usually free of anxiety, remorse, and quilt.  Violation of the law and customs of the local community is characteristic. The terms “sociopath” and “psychopath” have been applied to individuals with particularly deviant antisocial personalities.  Personality disorders are considered lifelong conditions, and the signs of conduct disorder must be present in adolescence. The criteria for conduct disorder should be met.  Persons who use illegal substances satisfy many of the criteria of antisocial personality disorder as a result of their pursuit of these substances. However, the diagnosis of antisocial personality disorder is not appropriate if the only diagnostic criteria are all drug related and
  64. 64. Cluster B – Antisocial Factors indicative of antisocial personality disorder include:  Current age of 18 years or older  Evidence of a conduct disorder with onset before age 15  A pervasive pattern of disregard for and violation of the rights of others occurring since age 15, as indicated by at least 3 of the following:  Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest  Irritability and aggressiveness, as indicated by repeated physical fights or assaults  Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations  Impulsivity or failure to plan ahead  Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure  Reckless disregard for safety of self or others  Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another person
  65. 65. Cluster B – Antisocial Summarily, Antisocial personality is marked by the callous disregard for the rights and feelings of other people. Affected people exploit others for materialistic gain or personal gratification. They become frustrated easily and tolerate frustration poorly. Characteristically, they act out their conflicts impulsively and irresponsibly, sometimes with hostility and violence. They usually do not anticipate the consequence of their behaviors and typically do not feel remorse or guilt afterwards. Many of them have a well-developed capacity for glibly rationalizing their behavior or blaming it on others. Dishonesty and deceit permeate their relationships. Punishment rarely modifies their behavior or improves their judgment. Antisocial personality often leads to alcoholism, drug addiction, promiscuity, failure to fulfill responsibilities, frequent relocation, and difficulty
  66. 66. CLUSTER C
  67. 67. Cluster C – Anxious and FearfulType This group includes avoidant, dependent, and obsessive- compulsive personalities. Affected individuals use defense mechanisms of isolation, passive-aggression, and hypochondriasis.  Isolation occurs when an unacceptable feeling, act, or idea is separated from the associated emotion. Patients are orderly and controlled and can speak of events in their lives without feeling.  Passive-aggression occurs when resistant is indirect and often turned against the self. Thus, failing examinations, clownish conduct, and procrastinating are aspects of passive-aggressive behavior.  Hypochondriasis is often present in patients with personality disorders, particularly in dependent, passive-aggressive patients. Biologically, these patients may have a tendency toward higher levels of cortical arousal and an increase in motor inhibition. Thus, stressful stimuli may lead to high
  68. 68. Cluster C – Anxious and FearfulType Twin studies have demonstrated some genetic factors in the development of cluster C personality disorders. For example, obsessive-compulsive traits are more common in monozygotic twins than in di-zygotic twins. Patients with obsessive-compulsive disorder are not at increased risk for obsessive-compulsive personality disorder and
  69. 69. Cluster C – Avoidant Avoidant patients are generally very shy. They display a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to rejection. Unlike patients with schizoid personality disorder, they actually desire relationships with others but are paralyzed by their fear and sensitivity into social isolation. A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation that began by early adulthood is indicative. Avoidant personality disorder, which is present in a variety of contexts, is indicated by at least 4 of the following:  Avoidance of occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection  Unwillingness to become involved with people unless certain of being liked.
  70. 70. Cluster C - Avoidant  Restraint in intimate relationships because of fear of being shamed or ridiculed  Preoccupation with worry about being criticized or rejected in social situations  Inhibition in new interpersonal situations because of feelings of inadequacy  Belief that he is socially inept, personally unappealing, or inferior to others  Unusual reluctance to take personal risks or engage in any new activities because they may prove embarrassing Avoidant Personality Disorder, APD is closely linked to a person’s temperament. Approximately 10% of toddlers have been found to be habitually fearful and withdrawn when exposed to new people and situations. This trait appears to be stable over time. Social anxiety is hypothesized to involve the amygdala and other areas of the brain’s limbic system, which, in affected individuals, is postulated to have a lower threshold of arousal and a more pronounced response when activated.
  71. 71. Cluster C - Avoidant Summarily, Avoidant personality is marked by hypersensitivity to rejection and fear of starting relationships or anything new because of the risk of failure or disappointment. Because affected people have a strong conscious desire for affection and acceptance, they are openly distressed by their isolation and inability to relate comfortably to other people. They respond to even small hints of rejection by withdrawing.
  72. 72. Cluster C – Obsessive-Compulsive People with obsessive-compulsive personality disorder are markedly preoccupied with orderliness, perfectionism, and control. They lack flexibility or openness. Their preoccupations interfere with their efficiency despite their focus on tasks. They are often scrupulous and inflexible about matters of morality, ethics, and values to a point beyond cultural norms. They are often stingy as well as stubborn. Individuals with obsessive-compulsive personality disorder display a pervasive pattern of preoccupation with orderliness, perfectionism, and environmental and interpersonal control, at the expense of flexibility, openness, and efficiency. This behavior begins by early adulthood and is present in a variety of contexts, as indicated by at least 4 of the following:  Preoccupation with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost  Perfectionism that interferes with task completion (e.g., inability to complete a project because one’s own overly strict standards are not met)
  73. 73. Cluster C – Obsessive-Compulsive  Excessive devotion to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity)  Over-conscientiousness, scrupulousness, and inflexibility about matters of morality, ethics, or values (not accounted for by cultural or religious identification)  Inability to discard worn-out or worthless objects even when they have no sentimental value  Reluctance to delegate tasks or to work with others unless they submit to exactly his way of doing things  Adoption of a miserly spending style toward both herself and others (money is viewed as something to be hoarded for future catastrophes)  Rigidity and stubbornness People with this disorder have few friends. They are difficult to live with and tend to drive people away. They may do very well in jobs that require detail and precision with little personal interaction. This disorder is more common in men, although the prevalence is not known with certainty.
  74. 74. Cluster C – Obsessive-Compulsive Summarily, Obsessive-compulsive personality is characterized by conscientiousness, orderliness, and reliability, but inflexibility often makes affected people unable to adapt to change. They take responsibilities seriously, but because they hate mistakes and incompleteness, they can become entangled with details and forget their purpose. As a result, they have difficulty making decisions and completing tasks. Such problems make responsibilities a source of anxiety, and they rarely enjoy much satisfaction from their achievements. Most obsessive-compulsive traits are adaptive, and as long as they are not too marked, people who have them often achieve much, especially in the sciences and other academic fields in which order, perfectionism and perseverance are desirable. However, they can feel uncomfortable with feelings, interpersonal relationships, and situations in which they lack control, they must rely on other people, or events are
  75. 75. Cluster C – Dependent While many people exhibit dependent behaviors and traits, people with dependent personality disorder have an excessive need to be taken care of that results in submissive and clinging behavior, regardless of consequences. These passive individuals allow others to direct their lives because they are unable to do so themselves. Other people such as spouses or parents make all the major life decisions, including where to live and what type of employment to obtain. The needs of dependent individuals are placed secondary to those of the people on whom they depend to avoid any possibility of having to be self-reliant. The dependent persons lack self-confidence and see themselves as helpless or stupid. Some authorities believe that the presence of this disorder depends to a large extent on cultural roles.
  76. 76. Cluster C - Dependent Diagnosis requires at least 5 of the following features:  Inability to make everyday decisions without an excessive amount of advice and reassurance from others  Need for others to assume responsibility for most major areas of the persons life  Difficulty expressing disagreement with others because of fear of loss of support or approval  Difficulty initiating projects or doing things on his own because of lack of confidence  Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant
  77. 77. Cluster C - Dependent  Feelings of discomfort or helplessness when alone because of exaggerated fears of being unable to care for himself  Urgent seeking of another relationship as a source of care and support when a close relationship ends  Unrealistic preoccupation with fears of being left to take care of himself Children who have a chronic physical illness or who have had separation anxiety may be at risk for this disorder in adulthood. The diagnosis is more frequent in women and youngest children.
  78. 78. Cluster C - Dependent Summarily, Dependent Personality is characterized by the surrender of responsibility to other people. Affected people may submit to others to gain and maintain support. For example, they often allow the needs of people they depend on to supersede their own. They lack self- confidence and feel intensely inadequate about taking care of themselves. They believe that others are more capable, and they are reluctant to express their view for fear that their aggressiveness will offend the people they need. Dependency in other personality disorders may be hidden by obvious behavioral problems; e.g., histrionic or borderline behavior mask underlying dependency.
  80. 80. Personality disorders notspecified Several other personality types have been described but are not classified as disorders in the DSM-IV-TR. This includes: Passive-aggressive (negativistic) personality – is a pattern of negative attitudes and passive resistance in interpersonal situations which typically produce the appearance of ineptness or passivity, but these behaviors are covertly designed to avoid responsibility or to control or punish other people. Passive- aggressive behavior is often evidenced by procrastination, inefficiency, or unrealistic protests of disability. Frequently, affected individuals agree to do tasks they do not want to do and then subtly undermine completion of the tasks. Such behavior usually serves to deny or conceal hostility or
  81. 81. Personality disorders notspecified Cyclothymic personality – alternates between high- spirited buoyancy and gloomy pessimism; each mood lasts weeks or longer. Characteristically, the rhythmic mood changes are regular and occur without justifiable external cause. When these features do not interfere with social adaptation, cyclothymia is considered a temperament and is present in many gifted and creative people.
  82. 82. Personality disorders notspecified Depressive personality – is a pervasive pattern of depressive cognitions and behaviors beginning by early adulthood. It is characterized by chronic moroseness, worry, and self-consciousness. Affected individuals have a pessimistic outlook, which impairs their initiatives and disheartens other people. Self- satisfaction seems undeserved and sinful. They unconsciously believe their suffering is a badge of merit needed to earn the love or admiration of others.
  83. 83. Personality disorders notspecified Sadistic personality – Sadism is a behavioral disorder characterized by a callous, vicious, manipulative, and degrading behavior expressed towards other people. To date, the exact cause of sadism is not known clearly. However, many theories have been given to explain the possible reasons underlying the development of a sadistic personality in an individual. Most of these theories commonly point out the fact that sadism is mainly dependent on the upbringing of an individual. Although biological and environmental aspects are also known to contribute to the development of this behavioral disorder, less evidence
  84. 84. Personality disorders notspecified Self-defeating personality – also known as masochistic personality disorder, according to the Proposed DSM-III, it is characterized by the following criteria: A pervasive pattern of self-defeating behavior, beginning by early adulthood and present in a variety of contexts. The person may often avoid or undermine pleasurable experiences, be drawn to situations or relationships in which he or she will suffer, and prevent others from helping him, as indicated by at least five of the following: chooses people and situations that lead to disappointment, failure, or mistreatment even when better options are clearly available  rejects or renders ineffective the attempts of others to help him or her  following positive personal events (e.g., new achievement), responds with depression, guilt, or a behavior that produces pain (e.g., an accident)  incites angry or rejecting responses from others and then feels hurt, defeated, or humiliated (e.g., makes fun of spouse in public, provoking an angry retort, then feels devastated)
  85. 85. Personality disorders notspecified  rejects opportunities for pleasure, or is reluctant to acknowledge enjoying himself or herself (despite having adequate social skills and the capacity for pleasure)  fails to accomplish tasks crucial to his or her personal objectives despite demonstrated ability to do so, e.g., helps fellow students write papers, but is unable to write his or her own  is uninterested in or rejects people who consistently treat him or her well, e.g., is un-attracted to caring sexual partners  engages in excessive self-sacrifice that is unsolicited by the intended recipients of the sacrifice The behaviors described above do not occur exclusively in response to, or in anticipation of, being physically, sexually, or psychologically abused. The behaviors described above do not occur only when the person is depressed.
  86. 86. Differential Diagnosis For the sake of simplicity, it is explicit to describe the differential diagnosis under the following heading:  Medical  Psychiatric
  87. 87. Differential diagnosis – Medical Mental Retardation secondary to medical condition or neurologic deficit Alcoholism
  88. 88. Differential diagnosis – Psychiatric Alcoholism Anxiety Disorders Brief Psychotic Disorder Bulimia Depression Dissociative Disorders Ganser Syndrome Hypochondriasis Mental Disorders Secondary to General Medical Conditions Paraphilias Posttraumatic Stress Disorder Schizoaffective Disorder Schizophrenia Schizophreniform Disorde Social Phobia
  89. 89. Investigations Toxicology screen: Substance abuse is common in many personality disorders, and intoxication can lead patients to present with some features of personality disorders. Screening for HIV and other sexually transmitted diseases: Patients with personality disorders often exhibit poor impulse control and many act without regard to risk. Psychological testing may support or direct the clinical diagnosis.  The Minnesota Multiphasic Personality Inventory (MMPI) is the best-known psychological test. The Eysenck Personality Inventory and the Personality Diagnostic Questionnaire are also used. None of these has been reliably validated against DSM-IV-TR diagnoses.  The Structured Clinical Interview for DSM-IV-TR for Axis II Disorders (SCID-II) can also be used to aid in diagnosis.
  91. 91. DSM IV Criteria for PersonalityDisorders DSM-IV-TR Criteria for Paranoid Personality Disorder: Presence of four or more of the following and not occurring exclusively during a course of schizophrenia, psychotic depression, or as part of a pervasive developmental disorder; also not due to a general medical condition:  Pervasive suspiciousness of being harmed, deceived, or exploited  Unwarranted doubts about the loyalty or trustworthiness of friends or associates  Reluctance to confide in others because of preceding criterion  Hidden meanings read into the innocuous actions of others  Grudges for perceived wrongs  Angry reactions to perceived attacks on character or reputation  Akin to first two criteria, unwarranted suspiciousness of the
  92. 92. DSM IV Criteria for PersonalityDisorders DSM-IV-TR Criteria for Schizoid Personality Disorder: Presence of four or more of the following and not occurring exclusively during a course of schizophrenia, psychotic depression, or as part of a pervasive developmental disorder; also not due to a general medical condition:  Lack of desire or enjoyment of close relationships.  Almost exclusive preference for solitude  Little interest in sex with others  Few, if any, pleasures  Lack of friends  Indifference to praise or criticism from others  Flat affect, emotional detachment
  93. 93. DSM IV Criteria for PersonalityDisorders DSM-IV-TR Criteria for Schizotypal Personality Disorder: Presence of five or more of the following and not occurring exclusively during a course of schizophrenia, psychotic depression, or as part of a pervasive developmental disorder; also not due to a general medical condition:  Ideas of reference  Peculiar beliefs or magical thinking e:g., belief in extrasensory perception  Unusual perceptions e.g., distorted beliefs about ones body  Peculiar patterns of speech  Extreme suspiciousness, paranoia  Inappropriate affect  Odd behavior or appearance  Lack of close friends  Extreme discomfort and sometimes extreme anxiety around
  94. 94. DSM IV Criteria for PersonalityDisorders DSM-IV-TR Criteria for Borderline Personality Disorder: Presence of five or more of the following:  Frantic efforts to avoid abandonment, both real and imagined  Instability and extreme intensity in interpersonal relationships, marked by splitting, that is, idealizing others in one moment and reviling them the next  Unstable sense of self  Impulsive behavior, including reckless spending and sexual promiscuity  Recurrent suicidal (gestures as well as genuine attempts) and self- mutilating behavior  Extreme emotional liability  Chronic feelings of emptiness  Extreme problems controlling anger  Paranoid thinking and dissociative symptoms triggered by stress
  95. 95. DSM IV Criteria for PersonalityDisorders DSM-IV-TR Criteria for Histrionic Personality Disorder: Presence of five or more of the following:  Strong need to be the center of attention  Inappropriate sexually seductive behavior  Rapidly shifting expression of emotions  Use of physical appearance to draw attention to self  Speech excessively impressionistic, passionately held opinions lacking in details  Exaggerated, theatrical emotional expression  Overly suggestible  Misreads relationships as being more intimate than they actually are.
  96. 96. DSM IV Criteria for PersonalityDisorders DSM-IV-TR Criteria for Narcissistic Personality Disorder: Presence of five or more of the following:  Grandiose view of one’s importance, arrogance  Preoccupation with one’s success, brilliance, beauty  Extreme need for admiration  Strong sense of entitlement  Tendency to exploit others  Envy of others
  97. 97. DSM IV Criteria for PersonalityDisorders DSM-IV-TR Criteria for Antisocial Personality Disorder: pervasive pattern of disregard for the rights of others since the age of 15 and at least three of the characteristics 1 through 7 plus 8 through 10: 1. Repeated law-breaking 2. Deceitfulness, lying 3. Impulsivity 4. Irritableness and aggressiveness 5. Reckless disregard for own safety and that of others 6. Irresponsibility as seen in unreliable employment history or not meeting finical obligations 7. Lack of remorse 8. Age at least 18 9. Evidence of conduct disorder before the age of 15 10. Antisocial behavior not occurring exclusively during episodes of schizophrenia or mania
  98. 98. DSM IV Criteria for PersonalityDisorders DSM-IV-TR Criteria for Avoidant Personality Disorder: presence of at least four of the following:  Avoidance of interpersonal contacts because of fears of criticism or rejection  Unwillingness to get involved with others unless certain of being liked  Restraint in intimate relationships for fear of being shamed or ridiculed  Preoccupation about being criticized or rejected  Feelings of inadequacy  Feelings of inferiority  Extreme reluctance to try new things for fear of being embarrassed.
  99. 99. DSM IV Criteria for PersonalityDisorders DSM-IV-TR Criteria for Obsessive-Compulsive Personality Disorder: presence of at least four of the following:  Preoccupation with rules and details to the extent that the major point of an activity is lost  Extreme perfectionism to the degree that projects are seldom completed  Excessive devotion to work to the exclusion of leisure and friendships  Difficulty discarding worthless items  Reluctance to delegate unless others conform to one’s standard  Miserliness  Rigidity and stubbornness
  100. 100. DSM IV Criteria for PersonalityDisorders DSM-IV-TR Criteria for Dependent Personality Disorder: presence of at least four of the following:  Difficulty making decisions without excessive advice and reassurance from others  Need for others to take responsibility for most major areas of life  Difficulty disagreeing with others for fear of losing their support  Difficulty doing things on own because of lack of self-confidence  Doing unpleasant things as a way to obtain the approval and support of others  Feelings of helplessness when alone because of lack of confidence in ability to handle things without the intervention of others  Urgently seeking of new relationship when present one ends  Preoccupation with fears of having to take care of self.
  101. 101. Treatment Treatment modality of MIMD will be discussed under the following headlines:  Psychological & Social – the gold standard  Biological
  102. 102. Treatment – Psychological &Social Psychotherapy is at the core of care for personality disorders. Because personality disorders produce symptoms as a result of poor or limited coping skills, psychotherapy aims to improve perceptions of and responses to social and environmental stressors.  Psychodynamic psychotherapy examines the ways that patients perceive events, based on the assumption that perceptions are shaped by early life experiences. Psychotherapy aims to identify perceptual distortions and their historical sources and to facilitate the development of more adaptive modes of perception and response. Treatment is usually extended over a course of several years at a frequency from several times a week to once a month; it makes use of transference.  Cognitive therapy (also called cognitive behavior therapy [CBT]) is based on the idea that cognitive errors based on long-standing beliefs influence the meaning attached to interpersonal events. It deals with how people think about their world and their perception of it. This very active form of therapy identifies the distortions and engages the patient in efforts to reformulate perceptions and behaviors. This therapy is typically limited to episodes of 6-20 weeks, once weekly. In the case of personality disorders, episodes of therapy are repeated often over the course of years.
  103. 103. Treatment – Psychological &Social Interpersonal therapy (IPT) conceives of patients difficulties resulting from a limited range of interpersonal problems including such issues as role definition and grief. Current problems are interpreted narrowly through the screen of these formulations, and solutions are framed in interpersonal terms. Therapy is usually weekly for a period of 6-20 sessions. Though empirically validated for anxiety and depression, IPT is not widely practiced, and therapists conversant in the technique are difficult to locate. Group psychotherapy allows interpersonal psychopathology to display itself among peer patients, whose feedback is used by the therapist to identify and correct maladaptive ideas, communication, and behavior. Sessions are usually once weekly over a course that may range from several months to years. Dialectical behavior therapy (DBT): This is a skills-based therapy (developed by Marsha Linehan, PhD) that can be used in both individual and group formats. It has been applied to borderline personality disorder. The emphasis of this manual-based therapy is on the development of coping skills to improve affective stability and impulse control and on reducing self-harmful behavior. This treatment
  104. 104. Treatment – Biological Medications are in no way curative for any personality disorder. They should be viewed as an adjunct to psychotherapy so that the patient may productively engage in psychotherapy. The focus is on treatment of symptom clusters such as cognitive-perceptual symptoms, affective dysregulation, and impulsive-behavioral dyscontrol. These symptoms may complicate almost all personality disorders to varying degrees, but all of them have been noted in borderline personality disorder. The assumption is that neurotransmitter abnormalities underlie these symptom clusters that transcend the concepts of Axis I and Axis II disorders. The strongest evidence for pharmacologic treatment of personality disorders has been for borderline personality disorder, but even this is based on a fairly small database of studies. Drug class commonly used includes:  Antidepressant  Antipsychotics  Anticonvulsants
  105. 105. Complications Suicide Substance abuse Accidental injury Depression Homicide - A potential complication, particularly in paranoid and antisocial personality disorders
  106. 106. Prognosis - overall Personality disorders are lifelong conditions. Attributes of cluster A and B personality disorders tend to become less severe and intense in middle age and late life. Patients with cluster B personality disorders are particularly susceptible to problems of substance abuse, impulse control, and suicidal behavior, which may shorten their lives. Cluster C characteristics tend to become exaggerated in later life.
  107. 107. Prevention Within the limits of contemporary medical knowledge, personality disorders cannot be prevented, although steps can be taken to prevent or deter some of the consequences and complications of personality disorders. Frequent inquiries about suicidal ideation are warranted, regardless of whether the patient spontaneously raises the subject. The physician need not fear instilling the idea of suicide in a patient who is not already entertaining it. Subsequent inquiry about firearms, lethal medications, and other available means of suicide point to avenues of preventive behavior. Benzodiazepines, narcotic analgesics, and other drugs with potential for dependency should be used rarely and with great caution. Nearly all personality disorders are marked by impaired impulse control and consequent risk of addictive behavior. Patients with personality disorder who have children should be asked frequently and in detail about their parenting practices. Their low frustration tolerance, externalization of blame for psychological distress, and impaired impulse control put the children of these patients at risk for neglect or abuse.
  108. 108. References dev.htm Mayo Foundation for Medical Education and Research Kaplan videos – General principles of Personality Disorders disorders/ds00562/dsection=causes Prof. Shuctov’s lecture on Personality Disorder, Psychiatric Department: Ryazan State .I.P. Pavlov Medical University, Russia. orders%20in%20the%20DSM.pdf