Personality disorders

1. PERSONALITY DISORDERS

2. INTRODUCTION
• Definition:
• Enduring pattern of behavior that differs markedly from the
expectation of the individual’s culture, is pervasive and
inflexible in which the onset is during the adolescence or
early adulthood, is stable over time resulting in social
impairment.
• Personality disorders are grouped into 3 clusters:
• Cluster A: odd or eccentric group
• Cluster B: dramatic, emotional and erratic group
• Cluster C: anxious and fearful group

3. EPIDEMIOLOGY
A study in 2012 titled "Prevalence of Personality Disorders in a Malaysian University Student Population"
reported that the overall prevalence of personality disorders was 27.7% among the studied population of
318 university students.
Personality Disorder %
Borderline personality disorder 11
Dependent personality disorder 7.2
Obsessive-compulsive personality
disorder
4.1
Avoidant personality disorder 3.8
Paranoid personality disorder 3.1
Histrionic personality disorder 1.9
Schizotypal personality disorder 1.3

4. CLUSTER A
1) PARANOID PERSONALITY
- Highly suspicious of others.
- Lacking basic trust.
- As a result, these leads to they do not have many friends -> social
lives limited -> difficulties in trusting others.
- Possible causes are genetics, pathological family life, marital
discord, broken home with childhood physical, emotional trauma
and abuse.

5. • Characteristics of paranoid personality are:
• Staying alone or has few friends.
• Often feels being victimized or harmed without sufficient basis.
• Highly sensitive, has low self-esteem, suspicious and inflexible in his/her
rights.
• Lack of trust.
• Difficulty in forgiving others and always has grudges.
• If married, always has suspicious regarding fidelity of the partner.
• Take criticism poorly.
• Belief that he/she is always right.
• Often involve in litigation on minor issues.

6. DSM DIAGNOSTIC CRITERIA
A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent,
beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the
following:
I. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
II. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
III. Is reluctant to confide in others because of unwarranted fear that the information will be used
maliciously against him or her.
IV. Reads hidden demeaning or threatening meanings into benign remarks or events.
V. Persistently bears grudges (unforgiving of insults, injuries or slights)
VI. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to
react angrily or to counterattack.
VII. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner
B. Does not occur exclusively during the course of schizophrenia, bipolar disorder or depressive disorder with
psychotic features, or another psychotic disorder and is not attributable to the physiological effects of
another medical condition.

7. 2) SCHIZOID PERSONALITY
• Characterized by a deeply pervasive pattern of withdrawal and detachment from social
environment as well as interpersonal relationships and emotion.
• Features are:
 Social isolation.
 Preference for solitary activities, spent time on themselves,
secretive. They are a loner and would avoid social interaction.
 Emotionally detached.
 Indifference not only to others but also with
family members. Indifference to praise or criticism.
 Could perform at work which does not need social interaction.
 No psychotic symptom.

8. DSM DIAGNOSTIC CRITERIA
A. A pervasive pattern of detachment from social relationships and a restricted range of expression of
emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts,
as indicated by four (or more) of the following:
I. Neither desires nor enjoys close relationships, including being part of a family.
II. Almost always chooses solitary activities.
III. Has little, if any, interest in having sexual experiences with another person.
IV. Takes pleasure in few, if any, activities.
V. Lacks close friends or confidants other than first-degree relatives.
VI. Appears indifferent to the praise or criticism of others.
VII. Show emotional coldness, detachment, or flattened affectivity.
B. Does not occur exclusively during the course of schizophrenia, bipolar disorder or depressive disorder
with psychotic features, or another psychotic disorder and is not attributable to the physiological
effects of another medical condition.

9. 3) SCHIZOTYPAL PERSONALITY
• Characterized by interpersonal relationship
problem, odd behavior and disturbances in
appearance and thought which include:
Odd beliefs, thinking, appearance
and speech.
Paranoid ideation.
Ideas of reference

10. DSM DIAGNOSTIC CRITERIA
A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced
capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior,
beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the
following:
I. Ideas of reference.
II. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms.
III. Unusual perceptual experiences including bodily illusions.
IV. Odd thinking and speech.
V. Suspiciousness or paranoid ideation.
VI. Inappropriate or constricted affect.
VII. Behavior or appearance that is odd, eccentric or peculiar.
VIII. Lack of close friends or confidants other than first-degree relatives.]
IX. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather
than negative judgements about self.
B. Does not occur exclusively during the course of schizophrenia, bipolar disorder or depressive disorder with
psychotic features, another psychotic disorder, or autism spectrum disorder.

11. CLUSTER B
1) ANTISOCIAL/PSYCHOPATHIC PERSONALITY DISORDER
• Characterized by persistent disregard of the rights of others that begins in
early adolescence (at least 18 years old), continues into adulthood and must
have some symptoms of Conduct Disorder (i.e. delinquency) before age 15.
• Risk factor may include:
• Exposure to previous physical abuse or neglect.
• Organic brain damage may have higher risk of developing violent or
criminal behaviors.
• Substance abuse.
• Attention deficit.

12. DSM DIAGNOSTIC CRITERIA
A. A pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years
old, as indicated by three (or more) of the following:
I. Failure to conform to social norms.
II. Deceitfulness (i.e. repeatedly lying, conning others for personal profits)
III. Impulsivity or failure to plan ahead.
IV. Irritability and aggressiveness. (i.e. repeated physical fights or assaults)
V. Reckless disregard for safety of self or others.
VI. Consistent irresponsibility.
VII. Lack of remorse.
B. The individual is at least age 18 years old.
C. There is evidence of conduct disorder with onset before age 15 years.
D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic
episode.

13. 2) BORDERLINE PERSONALITY DISORDER (BPD)*
• Main features are interpersonal relationship problem, poor impulse control,
unstable mood, poor self-image and chronic boredom.
• Can be easily mistaken with depressive and bipolar disorders as well as brief
psychotic disorders due to similar symptoms.
• BPD could be present together with either one of these disorders as
comorbids which indicates poor prognosis.
• Causes:
• Distressing childhood experiences ( physical, emotional, sexual abuses ).
• Family history.

14. DSM DIAGNOSTIC CRITERIA
A pervasive pattern of instability of interpersonal relationships, self-image
and affects and marked impulsivity, beginning in early adulthood and
present in a variety of contexts, as indicated by five (or more) of the
following:
I. Frantic effort to avoid real or imagined abandonment.
II. Pattern of unstable and intense interpersonal relationships
characterized by alternation between extremes of idealization and
devaluation.
III. Impulsivity in at least two areas that are potentially self-damaging
(e.g. substance abuse, binge eating, and reckless driving)
IV. Recurrent suicidal behaviour.
V. Affective instability due to marked reactivity of mood.
VI. Chronic feelings of emptiness.
VII. Inappropriate, intense anger or difficulty controlling anger.
VIII. Transient, stress-related paranoid ideation or severe dissociative
symptoms.

15. 3) HISTRIONIC PERSONALITY DISORDER
• Characterized by attention seeking.
• Main features of individuals with this disorders are dramatic,
seductive, easily sulk, flirtatious, tend to over-react to criticism
with a poor frustration tolerance.
• This personality is more common among woman.
• Can be caused by repeated learning behavior, hx of getting
excessive attention or pampered during their childhood days.

16. DSM DIAGNOSTIC CRITERIA
A pervasive pattern of excessive emotionally and attention seeking, beginning by early
adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
I. Is uncomfortable in situations in which he or she is not the center of attention.
II. Interaction with others is often characterized by inappropriate sexually seductive or
provocative behavior.
III. Displays rapidly shifting and shallow expression of emotions.
IV. Consistently uses physical appearance to draw attention to self.
V. Has a style of speech that is excessively impressionistic and lacking in detail.
VI. Shows self-dramatization, theatricality, and exaggerated expression of emotion.
VII. Is suggestible i.e. easily influenced by others or circumstances.
VIII. Considers relationships to be more intimate than they actually are.

17. 3) NARCISSTIC PERSONALITY
• Characterized by individuals having an inflated sense of their own
importance and a strong desire for admiration.
• They believe they are superior to others (harbors grandiose
feelings).
• And have little disregard for other’s feelings.
• At the same time, their self-esteem are fragile and
they are vulnerable to criticism.

18. DSM DIAGNOSTIC CRITERIA
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack empathy,
beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the
following:
I. Grandiose sense of self importance.
II. Preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
III. Believe that he/she is ‘special’ and unique and can only be understood by or should associate with
other special or high-status people.
IV. Requires excessive admiration.
V. Has a sense of entitlement (unreasonable expectations of especially favourable treatment).
VI. Interpersonally exploitive (takes advantage of others to achieve his/her own ends).
VII. Lacks empathy.
VIII. Often envious of others or believes that others are envious of him/her.
IX. Shows arrogant, haughty behaviours.

19. CLUSTER C
1) OBSESSIVE-COMPULSIVE
PERSONALITY DISORDER
• Sometimes referred as anankastic
personality disorder.
• Characterized by being a perfectionist,
extremely orderly, over-conscientious, overly organized,
highly disciplined and ambitious.
• Very particular with cleanliness and tidiness.
• The features are so severe that it leads to social impairment and significant
distress not only to affected person but also others.
• Male and female are equally prevalent.
• Parents who are highly authoritarian, over-controlling and highly disciplined
may contribute to this disorder.

20. DSM DIAGNOSTIC CRITERIA
A pervasive pattern of preoccupation with orderliness, perfectionism and mental and interpersonal
control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in
a variety of contexts, as indicated by four (or more) of the following:
I. Preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major
point of the activity is lost.
II. Shows perfectionism that interferes with task completion.
III. Excessively devoted to work and productivity to the exclusion of leisure activities and friendships.
IV. Overconscientious, scrupulous and inflexible about matters of morality, ethics, or values.
V. Unable to discard worn-out or worthless objects even when they have no sentimental value.
VI. Reluctant to delegates tasks or to work with others unless they submit to exactly his/her way of doing
thins.
VII. Adopts a miserly spending style toward both self and others; money is viewed as something to be
hoarded for future catastrophes.
VIII. Shows rigidity and stubbornness.

21. 2) DEPENDENT PERSONALITY DISORDER
• A pervasive and excessive need to be taken care of
associated with a clinging behavior and fears of
separation.
• May caused by parental over-control their children and
discourage their independence.

22. DSM DIAGNOSTIC CRITERIA
A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears
of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or
more) of the following:
I. Difficulty making everyday decisions without an excessive amount of advice and reassurance from
others.
II. Need others to assume responsibility for most major areas of his/her life.
III. Difficulty expressing disagreement with others because of fear of loss of support or approval.
IV. Difficulty initiating projects or doing things his/her own.
V. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering
to do things that are unpleasant.
VI. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for
him/herself.
VII. Urgently seeks another relationship as a source of care and support when a close relationship ends.
VIII. Unrealistically preoccupied with fears of being left to take care of him/herself.

23. 3) AVOIDANT
PERSONALITY
DISORDER
CHARACTERIZED BY EXTREME SHYNESS,
FEELINGS OF INADEQUACY, AND EXTREMELY
SENSITIVE TO REJECTION.

24. DSM DIAGNOSTIC CRITERIA
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation,
beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the
following:
I. Avoids occupational activities that involve significant interpersonal contact because fears of criticism,
disapproval or rejection.
II. Unwilling to get involved with people unless certain of being liked.
III. Shows restraint within intimate relationships because of fear of being shamed or ridiculed.
IV. Preoccupied with being criticized or rejected in social situations.
V. Inhibited in new interpersonal situations because of feelings of inadequacy.
VI. Views self as socially inept, personally unappealing or inferior to others.
VII. Unusually reluctant to take personal risks or to engage in any new activities because they may prove
embarrassing.

25. MANAGEMENT OF PATIENTS WITH PERSONALITY
DISORDERS
1) Assessments
- Perform comprehensive psychiatry evaluation which include:
- Full personal, family, occupational, past psy and medical hx, social hx
- Evaluate possible comorbid psy disorders, general medical conditions, substance abuse.
- Obtain info on work/school.
2) Treatment
- Combination of psychological and pharmacological treatments.
- Main mode is psychotherapy.

26. PSYCHOLOGICAL THERAPY
Generally involves:
Building therapeutic relationship.
Make an attempt to understand the patient’s difficulties and
respond to any crises.
Educate patient to deal with his/her Impulse control.
Suicidal risks assessment.

27. PHARMACOLOGICAL TREATMENT
Mainly to treat symptoms.
- If pt hv poor impulse control and mood instability, consider mood
stabilizing agents (i.e. carbamazepine, sodium valproate, lithium;
atypical antipsychotic and antidepressant)
- If pt hv anxiety and depressive sx: SSRI or benzodiazepine. (avoid
benzodiazepine group of drugs in antisocial personality disorder pt
because of risk of being abused)
- Pt with odd and detached behavior: antipsychotic