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B- Personality Disorders.pptx

This document provides information on various personality disorders. It discusses key aspects of different personality disorders like paranoid, schizoid, and schizotypal personality disorders. It covers epidemiology, clinical features, differential diagnosis, course, prognosis, and treatment approaches for these disorders. It also describes theories of personality development and assessment methods like various personality models and diagnostic instruments.

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Personality Disorders
• Personality refers to those enduring qualities of an individual that are shown in their ways of behaving in a wide variety of circumstances, and which we use to distinguish between people .
• Personality disorders behaviors are present throughout life • Mental disorders behaviours differ from the person’s previous behaviour. • Occurs in 10-20% of general population
• Symptoms : - ego syntonic (acceptable to ego) - alloplastic (adapt by trying to alter the external environment rather than themselves).
Importance of Personality • Predisposing factor for other psychiatric disorders (substance use, suicide, impulse- control disorder and anxiety disorders) • Colours the presentation of a psychiatric disorder • Affects approach to treatment.
Personality types • Different personality factors are derived from various traits like: - Anxiety - Energy - Flexibility - Hostility - Impulsiveness - Moodiness - Orderliness - Self reliance
• Investigators have derived different personality factors from such traits • Eysenck proposed 3 dimensions: - extroversion- introversion - Neuroticism - Psychoticism
• Cattell identified 5 factors - Openness to experience (novelty seeking) - Consciousness - Extroversion- introversion - Agreeableness - neuroticism
• Cloninger : - 3 basic behavioral dispositions expressed as 4 basic temperaments (a 7 factor model): 4 basic temperaments: - Novelty seeking - Harm reduction - Reward dependence - persistence
3 character traits: - Self directedness - Cooperativeness - transcendence
Etiology/ origin of personality • Genetic factors – twin studies- the concordance rate among MZ are higher than DZ twins . linkage studies- linkage between harm avoidance and a region on 8p21 has reported in one study
studies of body shape and personality – - 3 types of body built are described – 1. Pyknic (stocky and rounded) – - linked to cyclothymic personality type (sociable and variable mood)
2. Athletic (muscular) 3. Asthenic (lean and narrow) – - related to schizotypal personality type (cold, aloof and self-sufficient)
Biological factors • Hormones – - high levels of testosterone, 17-estradiol and estrone in persons who exhibit impulsive traits. • Platelet Monoamine oxidase – - low levels with schizotypal personality
• Smooth Pursuit Eye Movements – - saccadic in persons who are introverted, low self-esteem - seen in schizotypal personality disorder .
• Neurotransmitters – - roles of endorphins, serotonin and dopamine has been studied - low levels of 5- hydroxyindoleacetic (5-HIAA) in persons who attempt suicide and in impulsive and aggressive patients .
• Electrophysiology – - slow wave activity in antisocial and borderline personality disorders
Psychoanalytic factors – • Sigmund Freud – personality traits are related to a fixation at psychosexual stage for eg – - oral : passive and dependent - anal : stubborn, parsimonious and highly conscientious .
• Wilhelm Reich : - coined the term ‘character armor’ - defensive styles for protecting themselves from internal impulses.
Defense Mechanisms • To help those with personality disorders, psychiatrists must appreciate patients underlying defenses • Abandoning a defense increases conscious awareness of anxiety and depression- a major reason patients are reluctant to alter their behavior.
1. FANTASY: - seen in Schizoid PD - Person creates imaginary lives, especially imaginary friends. 2. DISSOCIATION and DENIAL : - replacement of unpleasant affects with pleasant ones. - histrionic personalities
3. ISOLATION: - Seen in obsessive-compulsive personalities. - intensified self-restraint, overly formal social behavior, and obstinacy.
4. PROJECTION: - patients attribute their own unacknowledged feelings to others 5. SPLITTING: - Persons toward whom patients' feelings are, or have been, ambivalent are divided into either completely good or bad
6. PASSIVE AGGRESSION: - Persons turn their anger against themselves. - phenomenon is called masochism - includes failure, procrastination, silly or provocative behavior and frankly self- destructive acts
7. ACTING OUT: - patients directly express unconscious wishes or conflicts through action to avoid being conscious of accompanying idea or affect. - Tantrums, motiveless assaults, child abuse, are common examples
8. PROJECTIVE IDENTIFICATION: - Seen in borderline personality disorder - consists of three steps. 1. aspect of self is projected onto someone else. 2. projector then tries to coerce the other person into identifying with what has been projected. 3. the recipient of the projection and the projector feel a sense of oneness or union
Childhood temperament and adult personality • Infants differ in patterns of sleeping and waking, intensity of emotional responses, span of attention • These differences could form the basis for personality development
Assessment of personality • Difficult : - Patient’s personality can only be judged by past behavior from various informants - Personality tests are used to assess personality but are difficult to apply in clinical practice
• It is best to record a series of a series of descriptive terms chosen from the features of accepted personality disorders which is fundamental element of good clinical practice like: - Sensitive - Prone to worry - Lacking in confidence
Instruments for diagnosing personality disorders 1. International personality disorders examination : - Assesses PD categorically and dimensionally - Semi structured clinical interview in 2 versions; a DSM IV version with 99 and ICD 10 version with 67 sets of questions
2. Structured clinical interview for DSM- IV axis II PD: - Semi structured clinical interview with 119 sets of questions
Personality change • Lasting personality change in adult life may be due to : - Injury to or organic disease of brain - Severe mental disorder - Exceptionally severe stressful events
ICD- 10 • Disorders of adult personality and behaviour: Specific personality disorders: Paranoid personality disorder Schizoid personality disorder Dissocial personality disorder Emotionally unstable personality disorder - Impulsive type - Borderline type
Histrionic personality disorder Anankastic personality disorder Anxious [avoidant] personality disorder Dependent personality disorder Other specific personality disorders Personality disorder, unspecified
Specific personality disorder (ICD 10) Diagnostic guidelines : Conditions not directly attributable to gross brain damage or disease, or to another psychiatric disorder, meeting the following criteria: (a) markedly disharmonious behaviour, involving usually several areas of functioning (b) the abnormal behaviour pattern is enduring, not just limited to episodes of mental illness
(c) pervasive and clearly maladaptive to a broad range of personal and social situations (d) appear during childhood or adolescence and continue into adulthood
(e) leads to considerable personal distress but this may only become apparent late in its course (f) usually, but not invariably, associated with significant problems in occupational and social performance.
Subtypes • Classified in DSM-5 • Cluster A – paranoid, schizoid, and schizotypal (odd, aloof features .) • Cluster B – antisocial, borderline, histrionic and narcissistic (dramatic, impulsive and erratic features .) • Cluster C – avoidant, dependent and obsessive - compulsive (anxious and fearful features )
Paranoid Personality Disorder • Epidemiology – • Prevalence – 2-4% in general population • Relatives of patients with schizophrenia show higher incidence • More in minority groups, immigrants and deaf people.
Clinical features • Hallmark – suspiciousness and distrust • Pervasive tendency to interpret actions of others as deliberately demanding or threatening • Frequent dispute, without any justification
• Bear grudges • Pathological jealous, question the fidelity of spouse • Ideas of reference and logically defended illusions are common • Affectively restricted and unemotional
• Pride themselves on being rational and objective • Pay close attention to power and rank • Use defense of projection
• They can be argumentative, often reading demeaning or threatening meaning into innocent remarks • Take offence easily and se rebuff where none was intended • Have sense of self importance and consider others have prevented them from fulfilling their potential
Differential Diagnosis • Delusional disorder • Borderline personality disorder • Antisocial personality disorder
Course and prognosis • No long term studies • In some patients it is lifelong • Others developed in to schizophrenia • Problems with working and living with others • Occupational and marital problems are common
Treatment • Psychotherapy – - Treatment of choice - Therapist should be straightforward and tried to maintain trust and tolerance - individual psychotherapy requires a professional and not overly warm style of therapists.
• These patients do not perform well in group therapy • Delusional accusations must be deal with realistic and gentle way without humiliating patient .
• Pharmacotherapy – Useful in dealing agitation and anxiety • Benzodiazepines • Antipsychotics
Schizoid Personality Disorder • Epidemiology – • Affects 5% of general population • M:F – 2:1
Diagnosis & Clinical features • Emotionally cold, detached and aloof • Quiet, distant, unsociable. • Introspective • Unable to express. • indifference to either praise or criticism • insensitivity to social norms and conventions.
• Little interest in sexual relationship • Do not form intimate relationship • Often remained unmarried
Differential diagnosis • Schizophrenia • Avoidant personality disorder • autistic disorder and Asperger's syndrome
Course and prognosis • Onset in early childhood or adolescence • May be life long .
Treatment • Psychotherapy – • Schizoid patients are introspective and are consistent with therapy • As trust develops, reveals fantasies, imaginary friends, and fears . • In group therapy , patient may be silent for long periods but involved .
• Pharmacotherapy – • Small doses of antipsychotics, antidepressants and psychostimulants • SSRIs make patient less sensitive to rejection • Benzodiazepines may help diminish interpersonal anxiety
Schizotypal Personality Disorder • Not classified as a personality disorder in ICD- 10 , but placed with schizophrenia and called schizotypal disorder .
Epidemiology • Occurs in about 3% of population • Sex ratio is unknown , frequently diagnosed in females with fragile X syndrome - DSM-5 suggests it is slightly more common in males
• More association among biological relatives of schizophrenia • Higher incidence among MZ twins than DZ
Diagnosis & Clinical features • Experience social anxiety – - have difficulties in forming relationship - lack friends - Feel different from other people
• Cognitive and perceptual distortions include – - ideas of reference (no delusions), - suspicious ideas - odd beliefs and - magical thinking (belief in clairvoyance, mind reading, telepathy) - unusual perceptual experiences (awareness of a ‘presence’ , or experiences bordering on hallucinations)
• Oddities of speech – - unusual constructions, words and phrasing, vagueness and tendency to digression . • Affective responses are unusual – - appear stiff, odd and constricted in their emotions .
• Behavior is eccentric, with odd mannerism, - unusual choices of clothing, - disregard of conventions and - awkward social behavior .
Differential diagnosis • Schizoid and avoidant personality disorders • Schizophrenia
Course and Prognosis • Considered as a premorbid personality of patient with schizophrenia . • Some persons maintains a stable schizotypal personality . • 10% patients eventually commit suicide .
Treatment • Psychotherapy – - Same as for schizoid personality disorder - Approach should be more sensitive as they have peculiar pattern of thinking and may involve in strange religious practices - Therapist must not ridicule such activities or be judgemental about these beliefs or activities .
• Pharmacotherapy – • Antipsychotics are useful in dealing with ideas of reference and illusions • Antidepressants when depressive component of personality is present .
Antisocial (Dissocial) Personality Disorder • Term ‘Dissocial’ is used in ICD-10
Epidemiology • 1 year prevalence rates are between 0.2 and 3% • More common in poor urban areas • Highest prevalence is seen with alcohol use disorder (over 70%) and in prison population (over 75%)
• More common in males • 5 times more common among first degree relatives of men with the disorder .
Diagnosis and clinical features • Patient can appear composed and credible, but beneath is tension, hostility, irritability and rage (described by Hervey Cleckley’s in the mask of sanity) . • Central feature is lack of concern for others .
• Exploitative , Violent and extremely manipulative • Sexual activity lacks tenderness • Inflict cruel or degrading acts on others • Partners may be physically or sexually abused
• Superficial charm, but their relationships are shallow and short-lived • Irresponsible and depart from social norms , do not obey rules and repeatedly break laws • Impulsive, rarely plans ahead and have an unstable work record
• Lack of guilt or remorse and failure to change their behavior in response to punishment or other adverse outcome • Avoid responsibility, transferring blames on other people and rationalizing their own failures .
Differential diagnosis • Criminal behavior • Substance abuse disorder
Course and prognosis • Unremitting course , peak of antisocial behaviour in late adolescence • Symptoms decrease as person grows older • Depressive disorder, alcohol use disorder and other substance abuse are common .
Treatment • Psychotherapy – - When hospitalized, become amenable to psychotherapy - Self-help groups are more useful - Before treatment begins, firm limits are essential , to deal with patients’ self destructive behaviour .
• Pharmacotherapy – - To deal with anxiety, rage and depression - If evidence of ADHD – psychostimulants such as methylphenidate is useful - Controlling impulsive behaviour – antiepileptic drugs as Carbamazepine , valproate - β-blockers to reduce aggression .
Borderline Personality Disorder • Patients stand on the border between neurosis and psychosis, characterized by extraordinarily unstable affect, mood, behaviour, object relations and self-image .
• The disorder has also been called as – - ambulatory schizophrenia (Helene Deutsch), - pseudoneurotic schizophrenia (Paul Hoch and Phillip Politan), and - psychotic character disorder (John Frosch).
• Otto Kernberg described it as involving – 1. Ego weakness with poor impulse control 2. ‘primary process’ ie. irrational thinking despite intact reality testing 3. Use of less mature defence mechanisms, such as projection and denial 4. Diffuse personal identity
Epidemiology • Present in about 1-2% of population • M:F = 1:2 • Increase prevalence of MDD, alcohol use disorder and substance abuse is found in first degree relatives .
Diagnosis and clinical features • ICD-10 uses the term emotionally unstable personality disorder , which is divided in to – - borderline type and - impulsive type (5 criteria for each subtype and 4 are required for diagnosis ).
• Borderline type – 1. Disturbed or uncertain self-image 2. Intense and unstable relationship 3. Efforts to avoid abandonment 4. Recurrent threats or acts of self harm 5. Chronic feeling of emptiness
• Impulsive type – - Impulsive - Liability to anger and violence - Unstable capricious mood - Quarrelsome - Difficulty maintaining a course of action
Clinical features • Life is dominated by strong and fluctuating emotions • Strive for affection and intimacy but regularly disappointed • Accept strangers as friends or behave promiscuously • Exhaust their partners with the intensity of their emotional demands • Confused by unpredictability of mood
• Insecure in their personal identity and need reassurance and stability • Self-harm is common (suicidal attempts or cutting to release tension) • Alcohol and drug abuse • Short lived psychotic episodes (micro- psychotic episodes) are seen
• Consider each person as either good or bad and due to this splitting good person is idealized and bad is devalued . • Some clinicians use the concept of panphobia, pananxiety , panambivalence and chaotic sexuality to delineate these patient’s characteristics .
Differential Diagnosis • Schizophrenia • Depressive and Bipolar disorders • Other personality disorders – - schizotypal and paranoid personality disorders • Personality change due to another medical condition • Substance use disorder
Course and Prognosis • Fairly stable , no progression towards schizophrenia • High incidence of major depressive episodes .
Treatment • Psychotherapy – - Difficult for therapists as patients regress easily, act out their impulses and show labile or fixed negative or positive transferences . - Splitting defence mechanism causes patients to alternately love and hate therapist
- A reality-oriented approach is more effective then in-depth interpretations of the unconscious. - Behaviour therapy to control impulses and anger - Social skill training
• DIALECTICAL BEHAVIOR THERAPY (DBT) - form of psychotherapy - used for patients with parasuicidal behavior • MENTALIZATION-BASED TREATMENT
• TRANSFERENCE-FOCUS PSYCHOTHERAPY - modified form of psychodynamic psychotherapy - based on Otto Kernberg’s object relation theory - involved 2 major working processes -
I. Clarification – - transference is analyzed more directly - patient becomes quickly aware of his distortions . ii. Confrontation – - therapists points out how these transferential distortions interfere with interpersonal relations towards others.
• Pharmacotherapy – - Antipsychotics to control anger, hostility and brief psychotic episode - Antidepressants - Benzodiazepines - Anticonvulsants – Carbamazepine
Histrionic Personality Disorder • Epidemiology – • 1-3% of general population • More in females • Increase association with somatization and alcohol use disorder.
Diagnosis and Clinical features • Self-dramatization : - emotional blackmail, angry scenes and demonstrative suicidal attempts • Easy suggestible and influenced by others • Seek attention and excitement, easily bored and have short-lived enthusiasms
• Shallow labile affect • Inappropriately seductive • Appear self centred and vain • Marked capacity for self-deception • Pathological liars and swindlers
• DSM-5 includes 2 additional criteria – - speech excessively impressionistic - consider relationships to be more intimate then they are .
Differential Diagnosis • Borderline personality disorder • Brief psychotic disorder and dissociative disorder may warrant a coexisting diagnosis
Course and Prognosis • Patients are attention seekers and may get into trouble with law, abuse substances and act promiscuously . • With age patient may show lesser symptom .
Treatment • Psychoanalytically oriented psychotherapy , group or individual , is the treatment of choice. • pharmacotherapy – - Antidepressants for depression and somatic complaints - Benzodiazepines for anxiety
Narcissistic personality disorder • Listed in DSM-5 • Epidemiology – • Occurs in 1-6% in general population • 50-70% are males
Diagnosis and Clinical features • Grandiose sense of self importance • Boastful and pretentious • Fantasizes about unlimited success, power, beauty or brilliance • Believes themselves special • Requires excessive admiration
• Sense of entitlement to favours and compliance • Exploits others • Lack empathy • Envious of others and believes that others envies them
Differential diagnosis • antisocial personality disorders • Mania or hypomania • Substance use disorder
Course and prognosis • Stable diagnosis • More vulnerable to midlife crises
Treatment • Psychotherapy : - chronic and difficult to treat
Avoidant Personality Disorder • Epidemiology : - Seen in 2-3% of general population
Diagnosis and Clinical features • Persistent and pervasive feeling of tension and apprehension • Feels insecure and lack self-esteem • Feels socially inferior, unappealing and socially inept • Preoccupied with rejection, disapproval or criticism
• Avoid risk and social activity • Few close friends • restraint in intimate relationships, due to fear of being shamed or ridiculed • inhibited in new personal situations, due to feeling of inadequacy
Differential diagnosis • Anxiety disorders (social phobia) • Schizoid personality disorder • Dependent personality disorder
Course and Prognosis • Shy and avoidant during adolescence • Able to function in a protected environment, if their support system fails, they are subjected to depression, anxiety and anger • Incur social phobia in the course of illness
Treatment • Psychotherapy – • Depends on solidifying an alliance with patients - therapist encourage the patient to take perceived risks • Group therapy is helpful
• Pharmacotherapy – - manage anxiety and depression - beta blockers to manage autonomic hyperactivity
Dependent Personality Disorder Epidemiology – • Prevalence – 0.6% • More common in young children • Increased rate in women • Person with chronic physical illness in childhood are more susceptible .
Diagnosis and Clinical features • characterized by dependant and submissive behavior • Allows others to take responsibility for important decisions in their lives • Unduly complaint, but unwilling to make direct demands • Feels unable to care for themselves
- Lacking self-reliance , avoid responsibility and need excessive help to make decisions - experiences difficulty in initiating projects - goes to excessive lengths to obtain help - urgently seeks a supportive relationship
• In folie a deux, one member of the pair usually has dependent personality disorder • An abusive, unfaithful or alcoholic spouse may be tolerated for long periods to avoid disturbing the sense of attachment
Differential diagnosis • Histrionic and borderline personality disorders • Schizoid and schizotypal personality disorder • Agoraphobia
Course and prognosis • Impaired occupational functioning • Limited social relationships • Risks MDD if they lose the person on whom they depend .
Treatment • Psychotherapy – • Treatment is often successful • Insight-oriented therapy • Behaviour therapy , assertiveness training, family therapy and group therapy
• Pharmacology – - treat anxiety and depression : Benzodiazepines and SSRIs
Obsessive-Compulsive Personality Disorder • ICD-10 used the term ‘Anankastic’ personality disorder .
• Epidemiology – • Prevalence- 2-8% • More common in men , diagnosed most often in oldest sibling.
• Freud hypothesized that the disorder is associated with the difficulties in anal stage of psychosexual development. • Defence mechanism used are – - rationalization, - intellectualization, - reaction formation - undoing.
Diagnosis & Clinical features • Preoccupied with details, rules, order and schedules • Inhibiting perfectionism and make ordinary work a burden • Lack imagination and fail to take advantage of opportunities • High moral standards
• Excessively conscientious and judgemental • Humourless and ill at ease when others are enjoying • Few friends • Rigid and inflexible, avoiding change and preferring a familiar routine • Eager to please those whom they see as more powerful then they are
• Stubborn and controlling • Hoard objects and money • Troubled by excessive doubt and caution, leading to indecision .
Differential diagnosis • Obsessive-compulsive disorder • Hoarding disorder • Delusional disorder
Course & Prognosis • Variable and unpredictable - some may develop obsession or compulsions - some evolve into warm, open and loving adults - other can develop into schizophrenia or major depressive disorder • Personal lives may remain barren
Treatment • Psychotherapy – • Patient often aware of their suffering and seek treatment on their own • Free association and no directive therapy • Treatment is often long and complex and countertransference problems are common .
• Pharmacotherapy – • SSRIs - useful in obsessive-compulsive signs and symptoms
B- Personality Disorders.pptx

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B- Personality Disorders.pptx

  • 1.
  • 2.
    • Personality refersto those enduring qualities of an individual that are shown in their ways of behaving in a wide variety of circumstances, and which we use to distinguish between people .
  • 3.
    • Personality disordersbehaviors are present throughout life • Mental disorders behaviours differ from the person’s previous behaviour. • Occurs in 10-20% of general population
  • 4.
    • Symptoms : -ego syntonic (acceptable to ego) - alloplastic (adapt by trying to alter the external environment rather than themselves).
  • 5.
    Importance of Personality •Predisposing factor for other psychiatric disorders (substance use, suicide, impulse- control disorder and anxiety disorders) • Colours the presentation of a psychiatric disorder • Affects approach to treatment.
  • 6.
    Personality types • Differentpersonality factors are derived from various traits like: - Anxiety - Energy - Flexibility - Hostility - Impulsiveness - Moodiness - Orderliness - Self reliance
  • 7.
    • Investigators havederived different personality factors from such traits • Eysenck proposed 3 dimensions: - extroversion- introversion - Neuroticism - Psychoticism
  • 8.
    • Cattell identified5 factors - Openness to experience (novelty seeking) - Consciousness - Extroversion- introversion - Agreeableness - neuroticism
  • 9.
    • Cloninger : -3 basic behavioral dispositions expressed as 4 basic temperaments (a 7 factor model): 4 basic temperaments: - Novelty seeking - Harm reduction - Reward dependence - persistence
  • 10.
    3 character traits: -Self directedness - Cooperativeness - transcendence
  • 11.
    Etiology/ origin ofpersonality • Genetic factors – twin studies- the concordance rate among MZ are higher than DZ twins . linkage studies- linkage between harm avoidance and a region on 8p21 has reported in one study
  • 12.
    studies of bodyshape and personality – - 3 types of body built are described – 1. Pyknic (stocky and rounded) – - linked to cyclothymic personality type (sociable and variable mood)
  • 13.
    2. Athletic (muscular) 3.Asthenic (lean and narrow) – - related to schizotypal personality type (cold, aloof and self-sufficient)
  • 14.
    Biological factors • Hormones– - high levels of testosterone, 17-estradiol and estrone in persons who exhibit impulsive traits. • Platelet Monoamine oxidase – - low levels with schizotypal personality
  • 15.
    • Smooth PursuitEye Movements – - saccadic in persons who are introverted, low self-esteem - seen in schizotypal personality disorder .
  • 16.
    • Neurotransmitters – -roles of endorphins, serotonin and dopamine has been studied - low levels of 5- hydroxyindoleacetic (5-HIAA) in persons who attempt suicide and in impulsive and aggressive patients .
  • 17.
    • Electrophysiology – -slow wave activity in antisocial and borderline personality disorders
  • 18.
    Psychoanalytic factors – •Sigmund Freud – personality traits are related to a fixation at psychosexual stage for eg – - oral : passive and dependent - anal : stubborn, parsimonious and highly conscientious .
  • 19.
    • Wilhelm Reich: - coined the term ‘character armor’ - defensive styles for protecting themselves from internal impulses.
  • 20.
    Defense Mechanisms • Tohelp those with personality disorders, psychiatrists must appreciate patients underlying defenses • Abandoning a defense increases conscious awareness of anxiety and depression- a major reason patients are reluctant to alter their behavior.
  • 21.
    1. FANTASY: - seenin Schizoid PD - Person creates imaginary lives, especially imaginary friends. 2. DISSOCIATION and DENIAL : - replacement of unpleasant affects with pleasant ones. - histrionic personalities
  • 22.
    3. ISOLATION: - Seenin obsessive-compulsive personalities. - intensified self-restraint, overly formal social behavior, and obstinacy.
  • 23.
    4. PROJECTION: - patientsattribute their own unacknowledged feelings to others 5. SPLITTING: - Persons toward whom patients' feelings are, or have been, ambivalent are divided into either completely good or bad
  • 24.
    6. PASSIVE AGGRESSION: -Persons turn their anger against themselves. - phenomenon is called masochism - includes failure, procrastination, silly or provocative behavior and frankly self- destructive acts
  • 25.
    7. ACTING OUT: -patients directly express unconscious wishes or conflicts through action to avoid being conscious of accompanying idea or affect. - Tantrums, motiveless assaults, child abuse, are common examples
  • 26.
    8. PROJECTIVE IDENTIFICATION: -Seen in borderline personality disorder - consists of three steps. 1. aspect of self is projected onto someone else. 2. projector then tries to coerce the other person into identifying with what has been projected. 3. the recipient of the projection and the projector feel a sense of oneness or union
  • 27.
    Childhood temperament andadult personality • Infants differ in patterns of sleeping and waking, intensity of emotional responses, span of attention • These differences could form the basis for personality development
  • 28.
    Assessment of personality •Difficult : - Patient’s personality can only be judged by past behavior from various informants - Personality tests are used to assess personality but are difficult to apply in clinical practice
  • 29.
    • It isbest to record a series of a series of descriptive terms chosen from the features of accepted personality disorders which is fundamental element of good clinical practice like: - Sensitive - Prone to worry - Lacking in confidence
  • 30.
    Instruments for diagnosingpersonality disorders 1. International personality disorders examination : - Assesses PD categorically and dimensionally - Semi structured clinical interview in 2 versions; a DSM IV version with 99 and ICD 10 version with 67 sets of questions
  • 31.
    2. Structured clinicalinterview for DSM- IV axis II PD: - Semi structured clinical interview with 119 sets of questions
  • 32.
    Personality change • Lastingpersonality change in adult life may be due to : - Injury to or organic disease of brain - Severe mental disorder - Exceptionally severe stressful events
  • 33.
    ICD- 10 • Disordersof adult personality and behaviour: Specific personality disorders: Paranoid personality disorder Schizoid personality disorder Dissocial personality disorder Emotionally unstable personality disorder - Impulsive type - Borderline type
  • 34.
    Histrionic personality disorder Anankasticpersonality disorder Anxious [avoidant] personality disorder Dependent personality disorder Other specific personality disorders Personality disorder, unspecified
  • 35.
    Specific personality disorder(ICD 10) Diagnostic guidelines : Conditions not directly attributable to gross brain damage or disease, or to another psychiatric disorder, meeting the following criteria: (a) markedly disharmonious behaviour, involving usually several areas of functioning (b) the abnormal behaviour pattern is enduring, not just limited to episodes of mental illness
  • 36.
    (c) pervasive andclearly maladaptive to a broad range of personal and social situations (d) appear during childhood or adolescence and continue into adulthood
  • 37.
    (e) leads toconsiderable personal distress but this may only become apparent late in its course (f) usually, but not invariably, associated with significant problems in occupational and social performance.
  • 38.
    Subtypes • Classified inDSM-5 • Cluster A – paranoid, schizoid, and schizotypal (odd, aloof features .) • Cluster B – antisocial, borderline, histrionic and narcissistic (dramatic, impulsive and erratic features .) • Cluster C – avoidant, dependent and obsessive - compulsive (anxious and fearful features )
  • 39.
    Paranoid Personality Disorder •Epidemiology – • Prevalence – 2-4% in general population • Relatives of patients with schizophrenia show higher incidence • More in minority groups, immigrants and deaf people.
  • 40.
    Clinical features • Hallmark– suspiciousness and distrust • Pervasive tendency to interpret actions of others as deliberately demanding or threatening • Frequent dispute, without any justification
  • 41.
    • Bear grudges •Pathological jealous, question the fidelity of spouse • Ideas of reference and logically defended illusions are common • Affectively restricted and unemotional
  • 42.
    • Pride themselveson being rational and objective • Pay close attention to power and rank • Use defense of projection
  • 43.
    • They canbe argumentative, often reading demeaning or threatening meaning into innocent remarks • Take offence easily and se rebuff where none was intended • Have sense of self importance and consider others have prevented them from fulfilling their potential
  • 44.
    Differential Diagnosis • Delusionaldisorder • Borderline personality disorder • Antisocial personality disorder
  • 45.
    Course and prognosis •No long term studies • In some patients it is lifelong • Others developed in to schizophrenia • Problems with working and living with others • Occupational and marital problems are common
  • 46.
    Treatment • Psychotherapy – -Treatment of choice - Therapist should be straightforward and tried to maintain trust and tolerance - individual psychotherapy requires a professional and not overly warm style of therapists.
  • 47.
    • These patientsdo not perform well in group therapy • Delusional accusations must be deal with realistic and gentle way without humiliating patient .
  • 48.
    • Pharmacotherapy –Useful in dealing agitation and anxiety • Benzodiazepines • Antipsychotics
  • 50.
    Schizoid Personality Disorder •Epidemiology – • Affects 5% of general population • M:F – 2:1
  • 51.
    Diagnosis & Clinicalfeatures • Emotionally cold, detached and aloof • Quiet, distant, unsociable. • Introspective • Unable to express. • indifference to either praise or criticism • insensitivity to social norms and conventions.
  • 52.
    • Little interestin sexual relationship • Do not form intimate relationship • Often remained unmarried
  • 53.
    Differential diagnosis • Schizophrenia •Avoidant personality disorder • autistic disorder and Asperger's syndrome
  • 54.
    Course and prognosis •Onset in early childhood or adolescence • May be life long .
  • 55.
    Treatment • Psychotherapy – •Schizoid patients are introspective and are consistent with therapy • As trust develops, reveals fantasies, imaginary friends, and fears . • In group therapy , patient may be silent for long periods but involved .
  • 56.
    • Pharmacotherapy – •Small doses of antipsychotics, antidepressants and psychostimulants • SSRIs make patient less sensitive to rejection • Benzodiazepines may help diminish interpersonal anxiety
  • 58.
    Schizotypal Personality Disorder •Not classified as a personality disorder in ICD- 10 , but placed with schizophrenia and called schizotypal disorder .
  • 59.
    Epidemiology • Occurs inabout 3% of population • Sex ratio is unknown , frequently diagnosed in females with fragile X syndrome - DSM-5 suggests it is slightly more common in males
  • 60.
    • More associationamong biological relatives of schizophrenia • Higher incidence among MZ twins than DZ
  • 61.
    Diagnosis & Clinicalfeatures • Experience social anxiety – - have difficulties in forming relationship - lack friends - Feel different from other people
  • 62.
    • Cognitive andperceptual distortions include – - ideas of reference (no delusions), - suspicious ideas - odd beliefs and - magical thinking (belief in clairvoyance, mind reading, telepathy) - unusual perceptual experiences (awareness of a ‘presence’ , or experiences bordering on hallucinations)
  • 63.
    • Oddities ofspeech – - unusual constructions, words and phrasing, vagueness and tendency to digression . • Affective responses are unusual – - appear stiff, odd and constricted in their emotions .
  • 64.
    • Behavior iseccentric, with odd mannerism, - unusual choices of clothing, - disregard of conventions and - awkward social behavior .
  • 65.
    Differential diagnosis • Schizoidand avoidant personality disorders • Schizophrenia
  • 66.
    Course and Prognosis •Considered as a premorbid personality of patient with schizophrenia . • Some persons maintains a stable schizotypal personality . • 10% patients eventually commit suicide .
  • 67.
    Treatment • Psychotherapy – -Same as for schizoid personality disorder - Approach should be more sensitive as they have peculiar pattern of thinking and may involve in strange religious practices - Therapist must not ridicule such activities or be judgemental about these beliefs or activities .
  • 68.
    • Pharmacotherapy – •Antipsychotics are useful in dealing with ideas of reference and illusions • Antidepressants when depressive component of personality is present .
  • 70.
    Antisocial (Dissocial) Personality Disorder •Term ‘Dissocial’ is used in ICD-10
  • 71.
    Epidemiology • 1 yearprevalence rates are between 0.2 and 3% • More common in poor urban areas • Highest prevalence is seen with alcohol use disorder (over 70%) and in prison population (over 75%)
  • 72.
    • More commonin males • 5 times more common among first degree relatives of men with the disorder .
  • 73.
    Diagnosis and clinicalfeatures • Patient can appear composed and credible, but beneath is tension, hostility, irritability and rage (described by Hervey Cleckley’s in the mask of sanity) . • Central feature is lack of concern for others .
  • 74.
    • Exploitative ,Violent and extremely manipulative • Sexual activity lacks tenderness • Inflict cruel or degrading acts on others • Partners may be physically or sexually abused
  • 75.
    • Superficial charm,but their relationships are shallow and short-lived • Irresponsible and depart from social norms , do not obey rules and repeatedly break laws • Impulsive, rarely plans ahead and have an unstable work record
  • 76.
    • Lack ofguilt or remorse and failure to change their behavior in response to punishment or other adverse outcome • Avoid responsibility, transferring blames on other people and rationalizing their own failures .
  • 77.
    Differential diagnosis • Criminalbehavior • Substance abuse disorder
  • 78.
    Course and prognosis •Unremitting course , peak of antisocial behaviour in late adolescence • Symptoms decrease as person grows older • Depressive disorder, alcohol use disorder and other substance abuse are common .
  • 79.
    Treatment • Psychotherapy – -When hospitalized, become amenable to psychotherapy - Self-help groups are more useful - Before treatment begins, firm limits are essential , to deal with patients’ self destructive behaviour .
  • 80.
    • Pharmacotherapy – -To deal with anxiety, rage and depression - If evidence of ADHD – psychostimulants such as methylphenidate is useful - Controlling impulsive behaviour – antiepileptic drugs as Carbamazepine , valproate - β-blockers to reduce aggression .
  • 82.
    Borderline Personality Disorder •Patients stand on the border between neurosis and psychosis, characterized by extraordinarily unstable affect, mood, behaviour, object relations and self-image .
  • 83.
    • The disorderhas also been called as – - ambulatory schizophrenia (Helene Deutsch), - pseudoneurotic schizophrenia (Paul Hoch and Phillip Politan), and - psychotic character disorder (John Frosch).
  • 84.
    • Otto Kernbergdescribed it as involving – 1. Ego weakness with poor impulse control 2. ‘primary process’ ie. irrational thinking despite intact reality testing 3. Use of less mature defence mechanisms, such as projection and denial 4. Diffuse personal identity
  • 85.
    Epidemiology • Present inabout 1-2% of population • M:F = 1:2 • Increase prevalence of MDD, alcohol use disorder and substance abuse is found in first degree relatives .
  • 86.
    Diagnosis and clinicalfeatures • ICD-10 uses the term emotionally unstable personality disorder , which is divided in to – - borderline type and - impulsive type (5 criteria for each subtype and 4 are required for diagnosis ).
  • 87.
    • Borderline type– 1. Disturbed or uncertain self-image 2. Intense and unstable relationship 3. Efforts to avoid abandonment 4. Recurrent threats or acts of self harm 5. Chronic feeling of emptiness
  • 88.
    • Impulsive type– - Impulsive - Liability to anger and violence - Unstable capricious mood - Quarrelsome - Difficulty maintaining a course of action
  • 89.
    Clinical features • Lifeis dominated by strong and fluctuating emotions • Strive for affection and intimacy but regularly disappointed • Accept strangers as friends or behave promiscuously • Exhaust their partners with the intensity of their emotional demands • Confused by unpredictability of mood
  • 90.
    • Insecure intheir personal identity and need reassurance and stability • Self-harm is common (suicidal attempts or cutting to release tension) • Alcohol and drug abuse • Short lived psychotic episodes (micro- psychotic episodes) are seen
  • 91.
    • Consider eachperson as either good or bad and due to this splitting good person is idealized and bad is devalued . • Some clinicians use the concept of panphobia, pananxiety , panambivalence and chaotic sexuality to delineate these patient’s characteristics .
  • 92.
    Differential Diagnosis • Schizophrenia •Depressive and Bipolar disorders • Other personality disorders – - schizotypal and paranoid personality disorders • Personality change due to another medical condition • Substance use disorder
  • 93.
    Course and Prognosis •Fairly stable , no progression towards schizophrenia • High incidence of major depressive episodes .
  • 94.
    Treatment • Psychotherapy – -Difficult for therapists as patients regress easily, act out their impulses and show labile or fixed negative or positive transferences . - Splitting defence mechanism causes patients to alternately love and hate therapist
  • 95.
    - A reality-orientedapproach is more effective then in-depth interpretations of the unconscious. - Behaviour therapy to control impulses and anger - Social skill training
  • 96.
    • DIALECTICAL BEHAVIORTHERAPY (DBT) - form of psychotherapy - used for patients with parasuicidal behavior • MENTALIZATION-BASED TREATMENT
  • 97.
    • TRANSFERENCE-FOCUS PSYCHOTHERAPY -modified form of psychodynamic psychotherapy - based on Otto Kernberg’s object relation theory - involved 2 major working processes -
  • 98.
    I. Clarification – -transference is analyzed more directly - patient becomes quickly aware of his distortions . ii. Confrontation – - therapists points out how these transferential distortions interfere with interpersonal relations towards others.
  • 99.
    • Pharmacotherapy – -Antipsychotics to control anger, hostility and brief psychotic episode - Antidepressants - Benzodiazepines - Anticonvulsants – Carbamazepine
  • 100.
    Histrionic Personality Disorder •Epidemiology – • 1-3% of general population • More in females • Increase association with somatization and alcohol use disorder.
  • 101.
    Diagnosis and Clinicalfeatures • Self-dramatization : - emotional blackmail, angry scenes and demonstrative suicidal attempts • Easy suggestible and influenced by others • Seek attention and excitement, easily bored and have short-lived enthusiasms
  • 102.
    • Shallow labileaffect • Inappropriately seductive • Appear self centred and vain • Marked capacity for self-deception • Pathological liars and swindlers
  • 103.
    • DSM-5 includes2 additional criteria – - speech excessively impressionistic - consider relationships to be more intimate then they are .
  • 104.
    Differential Diagnosis • Borderlinepersonality disorder • Brief psychotic disorder and dissociative disorder may warrant a coexisting diagnosis
  • 105.
    Course and Prognosis •Patients are attention seekers and may get into trouble with law, abuse substances and act promiscuously . • With age patient may show lesser symptom .
  • 106.
    Treatment • Psychoanalytically orientedpsychotherapy , group or individual , is the treatment of choice. • pharmacotherapy – - Antidepressants for depression and somatic complaints - Benzodiazepines for anxiety
  • 108.
    Narcissistic personality disorder •Listed in DSM-5 • Epidemiology – • Occurs in 1-6% in general population • 50-70% are males
  • 109.
    Diagnosis and Clinicalfeatures • Grandiose sense of self importance • Boastful and pretentious • Fantasizes about unlimited success, power, beauty or brilliance • Believes themselves special • Requires excessive admiration
  • 110.
    • Sense ofentitlement to favours and compliance • Exploits others • Lack empathy • Envious of others and believes that others envies them
  • 111.
    Differential diagnosis • antisocialpersonality disorders • Mania or hypomania • Substance use disorder
  • 112.
    Course and prognosis •Stable diagnosis • More vulnerable to midlife crises
  • 113.
    Treatment • Psychotherapy : -chronic and difficult to treat
  • 114.
    Avoidant Personality Disorder •Epidemiology : - Seen in 2-3% of general population
  • 115.
    Diagnosis and Clinicalfeatures • Persistent and pervasive feeling of tension and apprehension • Feels insecure and lack self-esteem • Feels socially inferior, unappealing and socially inept • Preoccupied with rejection, disapproval or criticism
  • 116.
    • Avoid riskand social activity • Few close friends • restraint in intimate relationships, due to fear of being shamed or ridiculed • inhibited in new personal situations, due to feeling of inadequacy
  • 117.
    Differential diagnosis • Anxietydisorders (social phobia) • Schizoid personality disorder • Dependent personality disorder
  • 118.
    Course and Prognosis •Shy and avoidant during adolescence • Able to function in a protected environment, if their support system fails, they are subjected to depression, anxiety and anger • Incur social phobia in the course of illness
  • 119.
    Treatment • Psychotherapy – •Depends on solidifying an alliance with patients - therapist encourage the patient to take perceived risks • Group therapy is helpful
  • 120.
    • Pharmacotherapy – -manage anxiety and depression - beta blockers to manage autonomic hyperactivity
  • 121.
    Dependent Personality Disorder Epidemiology– • Prevalence – 0.6% • More common in young children • Increased rate in women • Person with chronic physical illness in childhood are more susceptible .
  • 122.
    Diagnosis and Clinicalfeatures • characterized by dependant and submissive behavior • Allows others to take responsibility for important decisions in their lives • Unduly complaint, but unwilling to make direct demands • Feels unable to care for themselves
  • 123.
    - Lacking self-reliance, avoid responsibility and need excessive help to make decisions - experiences difficulty in initiating projects - goes to excessive lengths to obtain help - urgently seeks a supportive relationship
  • 124.
    • In foliea deux, one member of the pair usually has dependent personality disorder • An abusive, unfaithful or alcoholic spouse may be tolerated for long periods to avoid disturbing the sense of attachment
  • 125.
    Differential diagnosis • Histrionicand borderline personality disorders • Schizoid and schizotypal personality disorder • Agoraphobia
  • 126.
    Course and prognosis •Impaired occupational functioning • Limited social relationships • Risks MDD if they lose the person on whom they depend .
  • 127.
    Treatment • Psychotherapy – •Treatment is often successful • Insight-oriented therapy • Behaviour therapy , assertiveness training, family therapy and group therapy
  • 128.
    • Pharmacology – -treat anxiety and depression : Benzodiazepines and SSRIs
  • 129.
    Obsessive-Compulsive Personality Disorder • ICD-10used the term ‘Anankastic’ personality disorder .
  • 130.
    • Epidemiology – •Prevalence- 2-8% • More common in men , diagnosed most often in oldest sibling.
  • 131.
    • Freud hypothesizedthat the disorder is associated with the difficulties in anal stage of psychosexual development. • Defence mechanism used are – - rationalization, - intellectualization, - reaction formation - undoing.
  • 132.
    Diagnosis & Clinicalfeatures • Preoccupied with details, rules, order and schedules • Inhibiting perfectionism and make ordinary work a burden • Lack imagination and fail to take advantage of opportunities • High moral standards
  • 133.
    • Excessively conscientiousand judgemental • Humourless and ill at ease when others are enjoying • Few friends • Rigid and inflexible, avoiding change and preferring a familiar routine • Eager to please those whom they see as more powerful then they are
  • 134.
    • Stubborn andcontrolling • Hoard objects and money • Troubled by excessive doubt and caution, leading to indecision .
  • 135.
    Differential diagnosis • Obsessive-compulsivedisorder • Hoarding disorder • Delusional disorder
  • 136.
    Course & Prognosis •Variable and unpredictable - some may develop obsession or compulsions - some evolve into warm, open and loving adults - other can develop into schizophrenia or major depressive disorder • Personal lives may remain barren
  • 137.
    Treatment • Psychotherapy – •Patient often aware of their suffering and seek treatment on their own • Free association and no directive therapy • Treatment is often long and complex and countertransference problems are common .
  • 138.
    • Pharmacotherapy – •SSRIs - useful in obsessive-compulsive signs and symptoms