10. Personality-Disorders-Presentation-2017.pptx

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What is a personality disorder?
 Chronic, inflexible, and maladaptive pattern of relating to the
world.
 Evident in the way a person thinks, feels, and behaves.
 The most noticeable and significant feature is their negative
effect on interpersonal relationships.
 Relationships they do form are often fraught with problems
and difficulties.

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 Often those with personality disorders who experience
difficulties in their relationships or in their functioning don’t
believe that there is anything wrong with them
(egosyntonic).
 If anything, believe society (not them) should change –
alloplastic thinking.
 As a result maladaptive behaviour is repeated.

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 Differ from personality traits (ie. features of personality that
do not meet threshold for a PD).
 Diagnosis is warranted only if personality traits are:
 Inflexible, maladaptive, and enduring.
 Start in childhood/adolescence.
 Cause functional impairment/subjective distress.

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History
 First formal attempt to classify personality disorders
occurred in 1952 with the publication of DSM-I.
 7 personality disorders identified.
 Classification in various form throughout history.
 Hippocrates described 4 temperaments:
 earth, air, fire, and water
 the optimistic sanguine, the irritable choleric, the sad
melancholic, and the apathetic phlegmatic.
 Variation on the temperaments up to 20th
Century.

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Epidemiology
 Up to 10-20% of the general population.
 Greater in psychiatric samples – up to 30-50%.
 Antisocial Personality Disorder is the only PD with an age
specification (18 years) and that certain childhood
behaviours be present (conduct disorder).
 Some more frequent in men (ASPD).
 Some more frequent in women (BPD).

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Epidemiology
 Associated with impaired social, personal, and occupational
adjustment.
 Family life, marriage, academic and work difficulties.
 Increased rates of unemployment, homelessness, divorce
and separation, domestic violence and substance misuse.
 Increased rates of healthcare utilization.

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Epidemiology
 Individuals suffering from personality disorders are at high
risk of early death from suicide or accident.
 Suicide rate is as high as that seen for major depression.
 Although personality disorders tend to be stable, some
studies have shown that they tend to improve as a patient
ages.

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Epidemiology
 Presence of personality disorder is associated with poorer
response to treatment, particularly antidepressant
medication and electroconvulsive therapy.

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Etiology
 Historical psychoanalytical view theorized that personality
disorders occurred when an individual failed to progress
through appropriate psychosexual stage of development.
 Adverse childhood experience (abuse, maltreatment, or
neglect) is associated with risk for development of
personality disorder.
 Genetic association (eg. schizotypal and schizophrenia).

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Etiology
 Neurobiological correlates – eg. low levels of 5-
hydroxyindoleacetic acid (5-HIAA) a metabolite of serotonin
– linked to impulsivity and aggression (ASPD and BPD)
 Chronic nervous system under-arousal is thought to
contribute to thrill seeking, impulsivity and dangerousness in
ASPD.

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Etiology
 Interaction between an individual’s genetic predisposition
towards certain traits and an individual’s early experiences.
 Over time people develop habits of interpreting and
responding to the environment that influence the way they
experience and interpret their world ("personality traits”).
 Once these patterns have formed, they are maintained and
become fairly stable.

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Etiology
 Overdeveloped and underdeveloped behavioural strategies
specific to each personality disorder that are used across
situations and across time; even when the strategies are
dysfunctional.
 Strategies are developed to cope with highly negative core
beliefs.
 Strategies may have been adaptive when first developed.

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DSM-5 Diagnostic Criteria
 An enduring pattern of inner experience and behaviour that
deviates markedly from the expectations of the individual's
culture.
 Enduring pattern is inflexible and pervasive across range of
personal and social situations.
 Has an onset in adolescence or early adulthood and is stable
over time.

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 Symptoms must cause impairment in social, occupational, or
other important areas of functioning (ie. difficult for them to
function well in society) and /or subjective distress.
 Not better explained as a manifestation of another mental
disorder.
 Not attributable to substance or other medical condition (eg.
head trauma).

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 NOT diagnosed in children due to the requirement that
personality disorders represent enduring problems across
time.

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This enduring pattern manifests in 2 or more of the following
areas:
 Thinking - distorted thinking patterns
 Feeling - problematic emotional responses
 Impulse control – over/under regulated impulse control
 Interpersonal functioning - problematic relationships)

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Distorted Thinking Patterns
 Distortions in the way they interpret and think about the
world, and in the way they think about themselves.
 Thinking patterns may be extreme and distorted.

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Distorted Thinking Patterns
 Black-or-white thinking patterns
 Idealizing then devaluing other people or themselves.
 Distrustful, suspicious thoughts.
 Unusual or odd beliefs (contrary to cultural standards).
 Perceptual distortions and bodily illusions.

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Diagnosis
 Thorough personal and social history
 Mental Status Exam
 Collateral information – especially where the individual
denies or is unaware of their maladaptive traits.
 Caution in diagnosing when individual is suffering from
another mental disorder – eg depression (anxious,
dependent).

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Diagnosis
 Objective psychological testing may be of assistance in
diagnosing personality disorder.
 Eg. Minnesota Multiphasic Personality Inventory II

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DSM-5
 10 specific personality disorders
 3 clusters of personality disorders
 Each disorder has a set criteria of observable
characteristics.
 Diagnosis requires that a minimum number of criteria are
met.
 Can be co-occurrence/overlap in personality disorders.

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Clusters
 Cluster A - odd, eccentric
 Cluster B - dramatic, emotional, erratic
 Cluster C - anxious, fearful

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Cluster A (Odd, Eccentric)
 Paranoid
 Schizoid
 Schizotypal

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Cluster B (Dramatic, Emotional,
Erratic)
 Antisocial
 Borderline
 Histrionic
 Narcissistic

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Cluster C (Anxious, Fearful)
 Avoidant
 Dependent
 Obsessive-Compulsive

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Other Personality Disorders
 Personality Change Due to Another Medical Condition
 Other Specified Personality Disorder
 Symptoms characteristic of PD predominate but do not meet full
diagnostic criteria.
 Unspecified Personality Disorder
 Mixed or atypical traits that do not fit into better-defined
categories.

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Cluster A
 Characterized by a pervasive pattern of abnormal cognition
(eg. suspiciousness), self-expression (eg. odd speech), or
relating to others (eg. seclusiveness).

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Cluster A – Paranoid PD
 SUSPECT (4 criteria).
 S: Spouse fidelity suspected
U: Unforgiving (bears grudges)
S: Suspicious of others
P: Perceives attacks (and reacts quickly)
E: "Enemy or friend" (suspects associates, friends)
C: Confiding in others feared
T:Threats perceived in benign events

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 Expect exploitation.
 Misinterpret statements or acts as hostile
 Isolate to protect themselves.
 Rarely seek treatment because of their suspiciousness of
others (including therapists and psychiatrists).
 Tend to be identified when presenting for a mood or anxiety
disorder.

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 Prevalence ~4%. More common in males.
 Treatment involves supportive approach, treating the main
complaint, and once rapport is established alternative
explanations for misperceptions can be offered.

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Cluster A – Schizoid PD
 DISTANT (4 criteria).
 D: Detached (or flattened) affect
I: Indifferent to criticism and praise
S: Sexual experiences of little interest
T:Tasks (activities) done solitarily
A: Absence of close friends
N: Neither desires nor enjoys close relations
T:Takes pleasure in few activities

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 Profound defect in the ability to form personal relationships
and to respond to others in a meaningful way.
 No close relationships.
 Choose solitary activities
 Rarely experience strong emotions.
 Express little desire for sexual experience with another
person.

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 Indifferent to praise or criticism.
 Display constricted affect.
 Prevalence ~3%.
 Uncommon in psychiatric setting because they rarely seek
out psychiatric help except for co-occurring depression,
anxiety, substance abuse, etc.

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 Treat the identified disorder (eg. mood)
 May benefit from day or drop in programs.

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Cluster A – Schizotypal PD
 ME PECULIAR (5 criteria).
 M: Magical thinking or odd beliefs
E: Experiences unusual perceptions
 P: Paranoid ideation
E: Eccentric behaviour or appearance
C: Constricted (or inappropriate) affect
U: Unusual (odd) thinking and speech
L: Lacks close friends
I: Ideas of reference
A: Anxiety in social situations
R: Rule out psychotic disorders and pervasive developmental
disorder

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 Considered to be part of the schizophrenia spectrum.
 Characterized by a pattern of peculiar behaviour, odd
speech and thinking, and unusual perceptual experiences.
 Socially isolated
 Magical beliefs – eg. 6th
sense, supernatural experience
 Mild paranoia

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 Inappropriate or constricted affect
 Social anxiety
 Prevalence of 3-5% (common)
 Mood, anxiety, and substance use disorders common.

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 Treat the identified disorder.
 May benefit from social skills training.
 Goal is to help individual develop insight into their
behaviours and to develop repertoire of social skills.

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Cluster B (Dramatic, Emotional,
Erratic)
 Characterized by a pervasive pattern of violating social
norms (eg. criminal behaviour), impulsivity, excessive
emotionality, grandiosity,“acting out” (eg. tantrums, self-
abusive behaviour, angry outbursts), or violating the rights of
others (eg. criminal behaviour).

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Cluster B - ASPD
 CORRUPT (3 criteria).
 C: Conformity to law lacking
O: Obligations ignored
R: Reckless disregard for safety of self or others
R: Remorse lacking
U: Underhanded (deceitful, lies, cons others)
P: Planning insufficient (impulsive)
T:Temper (irritable and aggressive)

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Cluster B - ASPD
 Pervasive pattern of disregard for and violation of the rights
of others occurring since age 15 years.
 The individual is at least age 18 years.
 There is evidence of conduct disorder with onset before age
15 years.

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Cluster B - ASPD
 Conduct Disorder - TRAP
 T:Theft – B&E, deceiving, non-confrontational stealing
 R: Rule Breaking – running away, skipping school, out late
 A: Aggression – people, animals, weapons, forced sex
 P: Property Destruction

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Cluster B - ASPD
 First recognized in the early 19th
century.
 “Mania without delirium”
 “Moral insanity”
 Described immoral or guiltless behaviour in the absence of
impaired reasoning.
 20th
Century – termed psychopathic personality
 DSM-I – sociopathic personality

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Cluster B - ASPD
 DSM-III – antisocial personality disorder.
 Described in Hervey Cleckley’s – The Mask of Sanity (1941) –
identified 16 traits descriptive of the disorder.

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Cluster B - ASPD
 Typical childhood behaviour of fighting, lying, cheating,
stealing, fire setting, and cruelty to animals and other
children.
 As antisocial youth achieves adulthood, problems reflect age-
appropriate responsibilities – uneven job performance,
domestic abuse.

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Cluster B - ASPD
 Unreliability, reckless behaviour, inappropriate aggression,
criminal behaviour, pathological lying, and use of aliases are
characteristic.
 Often act impulsively without thinking of long-term
consequences. Legal issues common.

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Cluster B - ASPD
 2-4% of men.
 0.5 -1% of women.
 Higher amongst psychiatric, prison, and homeless
population.
 Chronic disorder but worse early on.

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Cluster B - ASPD
 Comorbid substance use disorders, mood and anxiety
disorders, ADHD, pathological gambling and other PDs
(BPD).
 Alcohol and SUD - 12 month prevalence
 AUD 28.6%, SUD 47.7%
 Any alcohol or SUD 84% lifetime
 Depression and Anxiety (1 study)
 35% MDE
 27% phobic disorder

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Cluster B - ASPD
 High death rate – suicide, accidents, homicides.
 No standard treatment.
 Target aggression – eg. mood stabilizer and antipsychotics.
 CBT to target distorted beliefs and attitudes.
 Emotion regulation / anger management.
 Difficult to treat due to treatment interfering traits – lie, blame
others, impulsive, low frustration tolerance.

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Psychopathy
 Psychopathy is a personality construct involving a
combination of both personality traits and behaviours.
 Most offenders who are psychopaths meet criteria for ASPD.

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Psychopathy
 3 key symptom groupings:
 Arrogant, interpersonally exploitative and deceitful interpersonal
style of relating.
 Shallow/deficient way of experiencing and expressing affect.
 Irresponsible, impulsive, antisocial behavioural lifestyle

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Psychopathy
 PCL-R is an operationalized checklist of Cleckley’s clinical
observations consisting of 20 items, composed of 2 factors (4
facets)

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Psychopathy
 Factor 1 (Affective/Interpersonal)
 Interpersonal:
 Glib/superficial
 Grandiose self-worth
 Pathological lying
 Conning/manipulative
 Affective:
 Lack of remorse/guilt
 Shallow affect
 Callous/lack of empathy
 Fail to accept responsibility for own actions

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Psychopathy
 Factor 2 (Behavioural/Antisocial)
 Behavioural (lifestyle)
 Stimulation seeking
 Parasitic lifestyle
 Lack of realistic goals
 Impulsivity
 Irresponsibility
 Antisocial
 Poor behavioural controls
 Early behaviour problems
 Juvenile delinquency
 Revocation of conditional release
 Criminal versatility

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Psychopathy
 2 additional items:
 Promiscuous sexual behaviour
 Many short term relationships

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Cluster B - BPD
 “Stably unstable” Pervasive pattern of:
 Mood instability
 Unstable and intense interpersonal relationships
 Impulsivity
 Inappropriate or intense anger
 Lack of control of anger
 Recurrent suicidal threats and gestures
 Self-mutilating behaviour

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Cluster B - BPD
 Marked and persistent identity disturbance
 Chronic feelings of emptiness or boredom
 Frantic efforts to avoid real or imagined abandonment
 Transient paranoid or dissociative symptoms

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Cluster B - BPD
 AM SUICIDE (5 criteria).
 A: Abandonment
M: Mood instability (marked reactivity of mood)
 S: Suicidal (or self-mutilating) behaviour
U: Unstable and intense relationships
I: Impulsivity (in two potentially self-damaging areas)
C: Control of anger
I: Identity disturbance
D: Dissociative (or paranoid) symptoms that are transient and
stress-related
E: Emptiness (chronic feelings of)

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Cluster B - BPD
 DSM-I – emotionally unstable personality
 Borderline schizophrenia – transient episodes of psychosis
 1-2% in general population
 10% of psychiatric outpatients
 15-25% of psychiatric inpatients
 Account for up to 50% of all persons with PDs.

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Cluster B - BPD
 Etiology unknown.
 Likely interaction between genetic vulnerability, life
experiences, reinforced interpersonal behaviours.
 Emotionally vulnerable temperament transacting with an
invalidating environment - Linehan 1993.

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Cluster B - BPD
 3:1 female to male
 Up to ¾ engage in in deliberate self-harm (cutting, burning,
over-dose)
 Reasons for SIB: to cause physical pain, control feelings,
express anger, overcome numbness
 SIB: cutting>bruising, biting, burning, head banging
 Up to 10% will commit suicide.

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Cluster B - BPD
 Frequent comorbid MDD, anxiety, and substance misuse.
 PTSD?
 Burnout with age – maturity, skills.
 Positive prognostic indicators: higher intelligence, self-
discipline, social support, lack of substance abuse, and lack
of history of abuse.
 Negative prognostic indicators: anger, antisocial behaviour,
suspiciousness, and vanity traits.

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Cluster B - BPD
 Treatment involves targeting mood, anxiety etc.
 DBT – reduces self-harm, hospitalization rates, and emotional
dyscontrol.
 DBT – targets dysfunctional attitudes and beliefs and
improves coping skills, stress tolerance, and emotion
regulation.
 Frequent acting out in therapy.

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Cluster B - BPD
 Treatment on an out-patient basis where patients can deal
with their issues.
 Hospitalization for acute/emergent issues. Risk of
regression/acting out/destabilization in hospital.
 Psychoeducation.

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Cluster B – Histrionic PD
 PRAISE ME (5 criteria)
 P: Provocative (or sexually seductive) behaviour
R: Relationships (considered more intimate than they are)
A: Attention (uncomfortable when not the center of attention)
I: Influenced easily
S: Style of speech (impressionistic, lacks detail)
E: Emotions (rapidly shifting and shallow)
 M: Made up (physical appearance used to draw attention to
self)
E: Emotions exaggerated (theatrical)

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 Show a pattern of excessive emotionality and attention-
seeking behaviour.
 Excessive concern with appearance.
 Wanting to be the centre of attention.
 Superficially charming.
 Manipulative, vain, demanding.

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 Prevalence – 2% general population
 More common in women.
 Seek out medical attention and make use of health services.

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 Treatment
 Supportive, problem solving, CBT to counter distorted
thinking.
 IPT to assist in targeting meaningful relationships.
 Group therapy to target provocative, attention seeking
behaviour.

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Cluster B – NPD
 SPECIAL (5 criteria).
 S: Special (believes he or she is special and unique)
P: Preoccupied with fantasies (of unlimited success, power,
brilliance, beauty, or ideal love)
E: Entitlement
C: Conceited (grandiose sense of self-importance)
I: Interpersonal exploitation
A: Arrogant (haughty)
L: Lacks empathy

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Cluster B – NPD
 Introduced in DSM-III
 Named after Narcissus from Greek mythology, who fell in
love with his own reflection.
 Characterized by grandiosity, lack of empathy, and
hypersensitivity to evaluation by others.
 Tend to be egotistical, inflate their accomplishments, and
manipulate/exploit those around them for their own aims.

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Cluster B – NPD
 Have an exaggerated sense of entitlement.
 Expect love and admiration but have little empathy for
others.
 Tend to have little insight into their own narcissism.
 1% prevalence. More common in males.

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Cluster B – NPD
 No consensus on treatment.
 Difficult to work with.
 Present after narcissistic injury sustained – anger or
depression post humiliation in a situation that they did not
get what they felt they were entitled to.
 CBT, dynamic psychotherapy.
 Treat comorbidities.

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Cluster C (Anxious, Fearful)
 Characterized by a pervasive pattern of abnormal fears
involving social relationships, separation, and need for
control.

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Cluster C – Avoidant PD
 CRINGES (4 criteria).
 C: Certainty (of being liked required before willing to get
involved with others)
R: Rejection (or criticism) preoccupies one's thoughts in social
situations
I: Intimate relationships (restraint in intimate relationships due
to fear of being shamed)
N: New interpersonal relationships (is inhibited in)
G: Gets around occupational activity (involving significant
interpersonal contact)
E: Embarrassment (potential) prevents new activity or taking
personal risks
S: Self viewed as unappealing, inept, or inferior

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 Predecessor – inadequate personality
 Tend to be inhibited, introverted, and anxious.
 Tend to have low self-esteem
 Rejection hypersensitivity
 Apprehensive and mistrustful
 Socially awkward and timid
 Fear being embarrassed or acting foolish in public.
 Overlap with social anxiety disorder.

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 Treatment:
 Assertiveness and social skills training.
 CBT – focus on sensitization to treat anxiety, shyness and
introversion.
 CBT – to target dysfunctional attitudes / thought distortion.
 Antidepressants (SSRIs) to target anxiety.

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Cluster C – Dependent PD
 RELIANCE (5 criteria).
 R: Reassurance required for decisions
E: Expressing disagreement difficult (due to fear of loss of
support or approval)
L: Life responsibilites (needs to have these assumed by others)
I: Initiating projects difficult (due to lack of self-confidence)
A: Alone (feels helpless and discomfort when alone)
N: Nurturance (goes to excessive lengths to obtain nurturance
and support)
C: Companionship (another relationship) sought urgently when
close relationship ends
E: Exaggerated fears of being left to care for self

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 Predecessor – subtype of DSM-1 passive-aggressive
personality
 Characterized by a pattern of relying excessively on others
for emotional support.
 Comorbid psychiatric disorders are common – mood,
anxiety, etc.
 Tend to have poor social supports because their
dependency promotes conflict.

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 Treatment
 Little consensus.
 Target associated mental disorder (mood, anxiety, etc.)
 CBT – assertiveness, effective decision making, and
independence.
 Assertiveness training and social skills training.

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Cluster C - OCPD
 LAW FIRMS (4 criteria).
 L: Loses point of activity (due to preoccupation with detail)
A: Ability to complete tasks (compromised by perfectionism)
W:Worthless objects (unable to discard)
 F: Friendships (and leisure activities) excluded (due to a
preoccupation with work)
I: Inflexible, scrupulous, overconscientious (on ethics, values,
or morality, not accounted for by religion or culture)
R: Reluctant to delegate (unless others submit to exact
guidelines)
M: Miserly (toward self and others)
S: Stubbornness (and rigidity)

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Cluster C - OCPD
 Characterized by obstinacy, parsimony, and orderliness.
 Lifelong pattern of perfectionism and inflexibility, associated
with over-conscientiousness and constricted emotions.
 No 1:1 relationship with OCD.
 Very common. In one study prevalence was estimated at up
to 8% of the general population.

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Cluster C - OCPD
 Patients suffering from OCPD are prone to major depression.
 Difficult to treat.
 CBT to target black and white thinking.
 Antidepressants to target mood, anxiety, and possibly
ritualized behaviour.

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Summary
 Personality Disorders encompass maladaptive, pervasive,
and deeply ingrained behaviour.
 Given the enduring, long-term nature of the maladaptive
patterns of behaviour, they cannot be easily reversed.

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