Personality disorders


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Personality disorders

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