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PERSONALITY DISORDERS

     Windsor University School of
              Medicine

          Psychiatry Rotation
  Consultant Psychiatrist – Dr. Sharon
               Halliday

             Presentation by:
OLADAPO SAMSON OLUWABUKOLA
               TH
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 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.
 Personality     disorders are a long-standing and
  maladaptive pattern of perceiving and responding to
  other people and to stressful circumstances.
An Overview of Human
Personality!
 Personality is the combination of thoughts, emotions and
 behaviors that makes you unique. It's 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. It's 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
An Overview of Human
Personality!
PERSONALITY
DEVELOPMENT &
   THEORIES
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
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 Piaget's discovery "so simple only a
  genius could have thought of it."
 Piaget's stage theory describes the cognitive development of children.
  Cognitive development involves changes in cognitive process and
  abilities. In Piaget's 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 Piaget's 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 child's 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.
Piaget’s Stages of Cognitive
Development
   Assimilation - The process of taking in new information into our
    previously existing schema's 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 child's 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
Freud’s Stages of Psychosexual
Development
  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.
  Freud's 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,
Freud’s Stages of Psychosexual
Development
STAG    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
Freud’s Stages of Psychosexual
Development
STAG      EROGENOU        AGE                             REMARKS
  E         S ZONE       RANG
                           E
Phallic    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 of
stage     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,
Freud’s Stages of Psychosexual
Development
  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 Freud's 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.
   Freud's 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
Freud’s Structural Model of
Personality
 According       to  Sigmund       Freud's     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 infant's 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 people's 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
Freud’s Structural Model of
Personality
 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
    id's 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 id's 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 id's 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.
Freud’s Structural Model of
Personality
   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 ego's 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.
Erikson’s Stages of Psychosocial
Development
 Erikson's theory describes the impact of social experience across
  the whole lifespan.
 One of the main elements of Erikson's 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 Erikson's 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 Erikson's 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.
Erikson’s Stages of Psychosocial
Development
 Psychosocial Stage 1 - Trust vs. Mistrust
   The first stage of Erikson's 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 child's 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 Erikson's 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, Erikson's reasoning was quite different then that of
    Freud's. Erikson believe that learning to control one's 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.
Erikson’s Stages of Psychosocial
Development
 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.
Erikson’s Stages of Psychosocial
Development
 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.
Kohlberg’s Stages of Moral
Development
 Lawrence Kohlberg who modified and expanded upon Jean
  Piaget's work to form a theory that explained the development of
  moral reasoning.
 Piaget described a two-stage process of moral development, while
  Kohlberg's theory of moral development outlined six stages within
  three      different    levels.    Kohlberg     extended     Piaget's
  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
Kohlberg’s Stages of Moral
Development
 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
Kohlberg’s Stages of Moral
Development
 Criticisms of Kohlberg's Theory of Moral Development:
   Does moral reasoning necessarily lead to moral behavior?
    Kohlberg's 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 Kohlberg's 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     Kohlberg's theory overemphasize Western
    philosophy? Individualistic cultures emphasize personal
    rights while collectivist cultures stress the importance of
    society and community. Eastern cultures may have
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.
Overview of Clusters
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%
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.
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. There's reluctance to diagnose personality disorders
     in a child, though, because the patterns of behavior and thinking
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 child's 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
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.
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.
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.
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.
Etiology - Social
 Other factors that have been cited as affecting
 children's 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
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 culture's 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.
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.
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
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           Depressive
Schizoid          Narcissistic       Dependent          Passive-
Schizotypal       Histrionic         Obsessive-         aggressive
                  Antisocial         compulsive         Sadistic
                                                        Self-defeating
                                                        Cyclothymic
CLUSTER A
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
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 Personality
Major 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
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
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.
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 person's 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
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
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.
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.
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.
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
CLUSTER B
CLUSTER B– Dramatic Emotional
Type
 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.
CLUSTER B– Dramatic Emotional
Type
   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.
Cluster B – Borderline
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
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
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.
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
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)
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)
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
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
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
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
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
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
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
CLUSTER C
Cluster C – Anxious and Fearful
Type
 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
Cluster C – Anxious and Fearful
Type
 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
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.
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.
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.
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)
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.
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
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.
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 person's 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
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.
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.
PERSONALITY DISORDERS
    NOT SPECIFIED
Personality disorders not
specified
 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
Personality disorders not
specified
 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.
Personality disorders not
specified
 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.
Personality disorders not
specified
 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
Personality disorders not
specified
 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)
Personality disorders not
specified
   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.
Differential Diagnosis
 For the sake of simplicity, it is explicit to describe the
  differential diagnosis under the following heading:
   Medical
   Psychiatric
Differential diagnosis – Medical
 Mental Retardation secondary to medical condition or
  neurologic deficit
 Alcoholism
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
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.
DSM IV CRITERIA FOR
   PERSONALITY
    DISORDERS
DSM IV Criteria for Personality
Disorders
 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
DSM IV Criteria for Personality
Disorders
 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
DSM IV Criteria for Personality
Disorders
 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 one's 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
DSM IV Criteria for Personality
Disorders
 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
DSM IV Criteria for Personality
Disorders
 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.
DSM IV Criteria for Personality
Disorders
 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
DSM IV Criteria for Personality
Disorders
 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
DSM IV Criteria for Personality
Disorders
 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.
DSM IV Criteria for Personality
Disorders
 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
DSM IV Criteria for Personality
Disorders
 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.
Treatment
 Treatment modality of MIMD will be discussed under
 the following headlines:
   Psychological & Social – the gold standard
   Biological
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.
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
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
Complications
 Suicide
 Substance abuse
 Accidental injury
 Depression
 Homicide - A potential complication, particularly in
 paranoid and antisocial personality disorders
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.
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.
References
 http://emedicine.medscape.com/article/1151826-overview#a7
 http://emedicine.medscape.com/article/805930-overview#a1
 http://emedicine.medscape.com/article/294307-overview
 http://psychology.about.com/od/personalitydevelopment/a/personality-
    dev.htm
   Mayo Foundation for Medical Education and Research
   Kaplan videos – General principles of Personality Disorders
   http://www.mayoclinic.com/health/personality-
    disorders/ds00562/dsection=causes
   http://www.apa.org/topics/personality/disorders-causes.aspx
   http://www.at-risk.org/blog/962/teen-paranoid-personality-disorder/
   Prof. Shuctov’s lecture on Personality Disorder, Psychiatric Department:
    Ryazan State .I.P. Pavlov Medical University, Russia.
   http://www.ivcc.edu/uploadedFiles/_faculty/_mangold/Personality%20Dis
    orders%20in%20the%20DSM.pdf
   http://en.wikipedia.org/wiki/Personality_disorder
   http://en.wikipedia.org/wiki/Self-defeating_personality_disorder
   http://en.wikipedia.org/wiki/Sadistic_personality_disorder

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PERSONALITY DISORDERS.ppt

  • 1. PERSONALITY DISORDERS Windsor University School of Medicine Psychiatry Rotation Consultant Psychiatrist – Dr. Sharon Halliday Presentation by: OLADAPO SAMSON OLUWABUKOLA TH
  • 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 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.  Personality disorders are a long-standing and maladaptive pattern of perceiving and responding to other people and to stressful circumstances.
  • 3. An Overview of Human Personality!  Personality is the combination of thoughts, emotions and behaviors that makes you unique. It's 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. It's 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. An Overview of Human Personality!
  • 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. 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 Piaget's discovery "so simple only a genius could have thought of it."  Piaget's stage theory describes the cognitive development of children. Cognitive development involves changes in cognitive process and abilities. In Piaget's 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 Piaget's 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 child's 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. Piaget’s Stages of Cognitive Development  Assimilation - The process of taking in new information into our previously existing schema's 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 child's 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. Freud’s Stages of Psychosexual Development  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.  Freud's 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. Freud’s Stages of Psychosexual Development STAG 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. Freud’s Stages of Psychosexual Development STAG EROGENOU AGE REMARKS E S ZONE RANG E Phallic 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 of stage 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. Freud’s Stages of Psychosexual Development  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 Freud's 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.  Freud's 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. Freud’s Structural Model of Personality  According to Sigmund Freud's 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 infant's 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 people's 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. Freud’s Structural Model of Personality  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 id's 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 id's 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 id's 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. Freud’s Structural Model of Personality  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 ego's 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. Erikson’s Stages of Psychosocial Development  Erikson's theory describes the impact of social experience across the whole lifespan.  One of the main elements of Erikson's 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 Erikson's 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 Erikson's 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. Erikson’s Stages of Psychosocial Development  Psychosocial Stage 1 - Trust vs. Mistrust  The first stage of Erikson's 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 child's 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 Erikson's 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, Erikson's reasoning was quite different then that of Freud's. Erikson believe that learning to control one's 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. Erikson’s Stages of Psychosocial Development  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. Erikson’s Stages of Psychosocial Development  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. Kohlberg’s Stages of Moral Development  Lawrence Kohlberg who modified and expanded upon Jean Piaget's work to form a theory that explained the development of moral reasoning.  Piaget described a two-stage process of moral development, while Kohlberg's theory of moral development outlined six stages within three different levels. Kohlberg extended Piaget's 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. Kohlberg’s Stages of Moral Development  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. Kohlberg’s Stages of Moral Development  Criticisms of Kohlberg's Theory of Moral Development:  Does moral reasoning necessarily lead to moral behavior? Kohlberg's 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 Kohlberg's 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 Kohlberg's theory overemphasize Western philosophy? Individualistic cultures emphasize personal rights while collectivist cultures stress the importance of society and community. Eastern cultures may have
  • 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.
  • 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. 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. 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. There's reluctance to diagnose personality disorders in a child, though, because the patterns of behavior and thinking
  • 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 child's 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. 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. 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. 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. 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. Etiology - Social  Other factors that have been cited as affecting children's 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. 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 culture's 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. 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. 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. 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 Depressive Schizoid Narcissistic Dependent Passive- Schizotypal Histrionic Obsessive- aggressive Antisocial compulsive Sadistic Self-defeating Cyclothymic
  • 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. 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 Personality Major 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. 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. 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. 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 person's 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. 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. 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. 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. 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. 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
  • 50. CLUSTER B– Dramatic Emotional Type  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. CLUSTER B– Dramatic Emotional Type  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. Cluster B – Borderline
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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
  • 67. Cluster C – Anxious and Fearful Type  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. Cluster C – Anxious and Fearful Type  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. 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. 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. 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. 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. 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. 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. 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. 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 person's 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. 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. 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.
  • 79. PERSONALITY DISORDERS NOT SPECIFIED
  • 80. Personality disorders not specified  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. Personality disorders not specified  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. Personality disorders not specified  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. Personality disorders not specified  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. Personality disorders not specified  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. Personality disorders not specified  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. Differential Diagnosis  For the sake of simplicity, it is explicit to describe the differential diagnosis under the following heading:  Medical  Psychiatric
  • 87. Differential diagnosis – Medical  Mental Retardation secondary to medical condition or neurologic deficit  Alcoholism
  • 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. 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.
  • 90. DSM IV CRITERIA FOR PERSONALITY DISORDERS
  • 91. DSM IV Criteria for Personality Disorders  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. DSM IV Criteria for Personality Disorders  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. DSM IV Criteria for Personality Disorders  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 one's 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. DSM IV Criteria for Personality Disorders  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. DSM IV Criteria for Personality Disorders  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. DSM IV Criteria for Personality Disorders  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. DSM IV Criteria for Personality Disorders  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. DSM IV Criteria for Personality Disorders  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. DSM IV Criteria for Personality Disorders  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. DSM IV Criteria for Personality Disorders  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. Treatment  Treatment modality of MIMD will be discussed under the following headlines:  Psychological & Social – the gold standard  Biological
  • 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. 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. 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. Complications  Suicide  Substance abuse  Accidental injury  Depression  Homicide - A potential complication, particularly in paranoid and antisocial personality disorders
  • 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. 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. References  http://emedicine.medscape.com/article/1151826-overview#a7  http://emedicine.medscape.com/article/805930-overview#a1  http://emedicine.medscape.com/article/294307-overview  http://psychology.about.com/od/personalitydevelopment/a/personality- dev.htm  Mayo Foundation for Medical Education and Research  Kaplan videos – General principles of Personality Disorders  http://www.mayoclinic.com/health/personality- disorders/ds00562/dsection=causes  http://www.apa.org/topics/personality/disorders-causes.aspx  http://www.at-risk.org/blog/962/teen-paranoid-personality-disorder/  Prof. Shuctov’s lecture on Personality Disorder, Psychiatric Department: Ryazan State .I.P. Pavlov Medical University, Russia.  http://www.ivcc.edu/uploadedFiles/_faculty/_mangold/Personality%20Dis orders%20in%20the%20DSM.pdf  http://en.wikipedia.org/wiki/Personality_disorder  http://en.wikipedia.org/wiki/Self-defeating_personality_disorder  http://en.wikipedia.org/wiki/Sadistic_personality_disorder