Personality Disorders HYACINTH C. MANOOD, M.D., F.P.P.A..
The totality of emotional and
behavioral traits that characterize the person in day-to-day living under
o Relatively stable and predictable.
Deeply ingrained, inflexible, and
maladaptive patterns of relating to
and perceiving both the environment
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
Cluster B - dramatic, impulsive, and erratic features
Cluster C - anxious and fearful features
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)
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.
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.
Be open and honest.
Have a professional and not overly
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
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.