Personality disorders
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Personality disorders






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Personality disorders Personality disorders Presentation Transcript

  • Personality Disorders HYACINTH C. MANOOD, M.D., F.P.P.A..
  • Personality
    • The totality of emotional and
    • behavioral traits that characterize the person in day-to-day living under
    • ordinary conditions.
    • o Relatively stable and predictable.
    • Deeply ingrained, inflexible, and
    • maladaptive patterns of relating to
    • and perceiving both the environment
    • and themselves.
    • influence cognition, affect, behavior
    • and interpersonal style.
    • Cause subjective distress or
    • significant functional impairment.
    • prevalence is estimated between 10 and 20 percent in the general population
    • frequently labeled as aggravating, demanding, or parasitic
    • generally considered to have poor prognosis.
    • alloplastic (i.e., changing the external environment)
    • ego-syntonic (i.e., acceptable to the ego).
    • Having an understanding of
    • personality disorders will improve the
    • relationship, enhance compliance, and
    • reduce their stress.
    • Axis II pathology affects the
    • predisposition, presentation, course,
    • and prognosis of Axis I pathology.
    • Cluster A - odd, aloof features
      • paranoid
      • schizoid
      • schizotypal.
    • Cluster B - dramatic, impulsive, and erratic features
      • Borderline
      • Antisocial
      • Narcissistic
      • histrionic.
    • Cluster C - anxious and fearful features
      • Avoidant
      • Dependent
      • Obsessive -compulsive
    • Cluster A personality disorders are more common in the biological relatives of patients with schizophrenia than in control groups
    • Antisocial personality disorder is associated with alcohol use disorders
    • Depression is common in the family backgrounds of patients with borderline personality disorder
    • A strong association is found between histrionic personality disorder and somatization disorder (Briquet's syndrome);
    • Patients with avoidant personality disorder often have high anxiety levels
    • Patients with obsessive-compulsive personality disorder show some signs associated with depression
    • Persons who exhibit impulsive traits also often show high levels of testosterone, 17-estradiol, and estrone
  • DSM-IV-TR General Diagnostic Criteria for a Personality Disorder
    • An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas:
      • cognition (i.e., ways of perceiving and interpreting self, other people, and events)
      • affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)
      • interpersonal functioning
      • impulse control
    • The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
    • The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    • The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
    • The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.
    • The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).
    • Sigmund Freud suggested that personality traits are related to a fixation at one psychosexual stage of development.
    • Wilhelm Reich subsequently coined the term character armor to describe persons' characteristic defensive styles for protecting themselves from internal impulses and from interpersonal anxiety in significant relationships.
    • internal object relations - internal self-representations and object representations
      • Through introjection, children internalize a parent or another significant person as an internal presence that continues to feel like an object rather than a self.
      • Through identification, children internalize parents and others in such a way that the traits of the external object are incorporated into the self and the child owns the traits.
      • through externalization and projective identification, are played out in interpersonal scenarios in which others are coerced into playing a role in the person's internal life.
    • Defense Mechanisms :
    • Fantasy - seek solace and satisfaction within themselves by creating imaginary lives, especially imaginary friends.
      • schizoid
    • Dissociation or denial is a Pollyanna-like replacement of unpleasant affects with pleasant ones.
      • dramatizing and emotionally shallow; they may be labeled histrionic personalities.
    • Isolation is characteristic of the orderly, controlled persons who are often labeled obsessive-compulsive personalities
    • Projection - patients attribute their own unacknowledged feelings to others.
      • excessive faultfinding and sensitivity
      • Counterprojection- Clinicians acknowledge and give paranoid patients full credit for their feelings and perceptions; they neither dispute patients' complaints nor reinforce them, but agree that the world described by patients is conceivable.
    • Splitting - persons toward whom patients' feelings are, or have been, ambivalent are divided into good and bad.
    • Passive –aggression- turn their anger against themselves.
      • includes failure, procrastination, silly or provocative behavior, self-demeaning clowning, and frankly self-destructive acts.
    • Acting out- patients directly express unconscious wishes or conflicts through action to avoid being conscious of either the accompanying idea or the affect.
      • Tantrums, apparently motiveless assaults, child abuse, and pleasureless promiscuity
    • Projective identification - appears mainly in borderline personality disorder and consists of three steps :
      • an aspect of the self is projected onto someone else.
      • tries to coerce the other person into identifying with what has been projected
      • the recipient of the projection and the projector feel a sense of oneness or union.
  • Paranoid Personality Disorder
    • characterized by long-standing suspiciousness and mistrust of persons in general.
    • often hostile, irritable, and angry.
    • Bigots, injustice collectors, pathologically jealous spouses, and litigious cranks
    • prevalence - 0.5 to 2.5% of the general population.
    • more common in men than in women
    • hallmarks are excessive suspiciousness and distrust of others expressed as a pervasive tendency to interpret actions of others as deliberately demeaning, malevolent, threatening, exploiting, or deceiving.
    • Psychotherapy is the treatment of choice
    • Pharmacotherapy is useful in dealing with agitation and anxiety.
    • Pimozide (Orap) has successfully reduced paranoid ideation in some patients.
    • Acknowledge mistakes.
    • Be open and honest.
    • Have a professional and not overly
    • warm style.
    • Don’t confront.
    • Set limits.
    • Clearly explain procedures,
    • medications and results.
  • Schizoid Personality Disorder
    • display a lifelong pattern of social withdrawal.
    • discomfort with human interaction, their introversion, and their bland, constricted affect
    • eccentric, isolated, or lonely.
    • prevalence is 7.5 % of the general population
    • solitary interests and success at noncompetitive, lonely jobs that others find difficult to tolerate.
    • treatment is similar to that of those with paranoid personality disorder.
    • Understand their need for isolation.
    • Minimize new contacts and intrusions.
    • Maintain a quiet, reassuring, and
    • considerate interest in them.
    • Don’t insist on reciprocal responses.
  • Schizotypal Personality Disorder
    • strikingly odd or strange
    • Magical thinking, peculiar notions, ideas of reference, illusions, and derealization
    • occurs in about 3 percent of the population
    • diagnosed on the basis of the patients' peculiarities of thinking, behavior, and appearance.
    • Similar to Schizoid PD.
    • Misperceptions of physical symptoms
    • and treatment.
    • Do not ridicule or judge.
    • Respect their need for privacy.
  • Antisocial Personality Disorder
    • an inability to conform to the social norms that ordinarily govern many aspects of a person's adolescent and adult behavior.
    • prevalence is 3% in men and 1% in women.
    • onset of the disorder is before the age of 15.
    • Lying, truancy, running away from home, thefts, fights, substance abuse, and illegal activities
    • highly representative of so-called con men
    • notable finding is a lack of remorse for these actions; that is, they appear to lack a conscience.
    • self-help groups
    • firm limits are essential
    • Pharmacotherapy
    • Set firm limits.
    • Try not to be manipulated.
    • Have high level of skepticism.
    • Be careful not to prescribe excessive
    • and/or unnecessary medications.
  • Borderline Personality Disorder
    • emotionally unstable personality disorder
    • 1 to 2 percent of the population
    • twice as common in women as in men
    • almost always appear to be in a state of crisis.
    • Mood swings are common.
    • micropsychotic episodes - short-lived psychotic episodes
    • have tumultuous interpersonal relationships.
    • Shifts of allegiance from one person or group to another are frequent.
    • Be aware of and anticipate defenses.
    • Often regress.
    • Open and continuous communication with
    • staff.
    • Stable and calm reaction.
    • Gently confront.
    • Set fair and consistent limits on acting out.
  • Histrionic Personality Disorder
    • excitable and emotional and behave in a colorful, dramatic, extroverted fashion
    • inability to maintain deep, long-lasting attachments
    • prevalence - 2 to 3%
    • high degree of attention-seeking behavior
    • display temper tantrums, tears, and accusations when they are not the center of attention or are not receiving praise or approval.
    • Seductive behavior is common
    • major defenses are repression and dissociation.
    • With age, show fewer symptoms, but because they lack the energy of earlier years, the difference in number of symptoms may be more apparent than real
    • Similar to Borderline PD.
    • Medical illnesses threaten their sense
    • of attractiveness and self-image.
  • Narcissistic Personality Disorder
    • characterized by a heightened sense of self-importance and grandiose feelings of uniqueness
    • than 1 percent in the general population
    • sense of entitlement is striking
    • handle criticism poorly and may become enraged when someone dares to criticize them
    • Interpersonal exploitiveness is commonplace
    • cannot show empathy, and they feign sympathy only to achieve their own selfish ends.
    • Handle criticism poorly.
    • Become easily enraged.
    • Medical illnesses can be a blow to
    • their self-esteem.
    • Reinforce that they are respected
    • and appreciated.
    • Set limits on demanding behavior.
  • Avoidant Personality Disorder
    • show extreme sensitivity to rejection and may lead a socially withdrawn life.
    • not asocial and show a great desire for companionship, but they need unusually strong guarantees of uncritical acceptance.
    • prevalence - 1-10% of the general population
    • most striking aspect is anxiety
    • Hypersensitivity to rejection by others is the central clinical feature
    • main personality trait is timidity
    • Have patience and understanding.
    • Medical illnesses may be
    • embarrassing.
    • Minimize new and unfamiliar staff
    • contacts.
    • Respond with a calm and reassuring
    • demeanor.
    • Do not criticize them.
  • Dependent Personality Disorder
    • characterized by a pervasive pattern of dependent and submissive behavior.
    • cannot make decisions without an excessive amount of advice and reassurance from others.
    • more common in women than in men.
    • Pessimism, self-doubt, passivity, and fears of expressing sexual and aggressive feelings all typify the behavior
    • An abusive, unfaithful, or alcoholic spouse may be tolerated for long periods to avoid disturbing the sense of attachment.
    • Respect their feelings of attachment.
    • Be careful when encouraging a patient
    • to change the dynamics of an abusive
    • relationship.
    • When medically ill they may become
    • frustrated that they are not being helped.
    • Be active in the treatment planning.
  • Obsessive-Compulsive Personality Disorder
    • anancastic personality disorder
    • characterized by emotional constriction, orderliness, perseverance, stubbornness, and indecisiveness
    • essential feature of the disorder is a pervasive pattern of perfectionism and inflexibility
    • preoccupied with rules, regulations, orderliness, neatness, details, and the achievement of perfection.
    • lack flexibility and are intolerant.
    • capable of prolonged work, provided it is routinized and does not require changes to which they cannot adapt.
    • Give precise and rational explanations.
    • Value efficiency and punctuality.
    • Medical illnesses create a disruption in the patient’s work, orderly lifestyle, and sense of control.
    • Acknowledge the importance of work, but point out how avoiding treatment may have harmful consequences.
    • Allow the patient to control his or her care as much as possible.
    • Provide them with information.
    • Avoid power struggles.
    • Understand their need for order and control.