PERSONALITY DISORDER

1. CLUSTER A
PERS NALITY
DISORDER
PRESENTATOR : DR. RAMASHANKAR

2. DEFINITION
PERSONALITY can be defined as the totality of the person’s
emotional and behavioural traits that characterise their day-to-
day living. *
PERSONALITY DISORDERS are deeply ingrained, maladaptive
patterns of behaviour, generally recognisable by adolescence and
continuing throughout adult life.*
 * Fish’s clinical psychopathology 3rd ed. Pg-106.

3. When personality traits are rigid and maladaptive and
produce functional impairment or subjective distress, a
personality disorder may be diagnosed.
CHARACTER:
Conceptual core of personality
It involves individual differences in self concepts and object
relations that reflects persons goal and value.

4. PERSONALITY DISORDER
Occur in 10 to 20 percent of the general population
Approximately 50 percent of all psychiatric patients have a
personality disorder
Predisposing factor for other psychiatric disorder
PD symptoms are ego syntonic and Alloplastic
Persons with PD do not feel anxiety about their maladaptive
behavior.

5. GENERAL PERSONALITY
DISORDER (DSM-5)
An enduring pattern of behavior and inner experiences that
deviates significantly from the individual's cultural standards;
Rigidly pervasive
Onset in adolescence or early adulthood; and stable through
time
Leads to unhappiness and impairment
Manifests in at least two of the following four areas: cognition,
affectivity, interpersonal function, or impulse control
Not due to any medical condition ,substance use or any mental
disorder.

6. CLASSIFICATION
Cluster A Cluster B Cluster C
Odd, aloof features Dramatic, impulsive,
and erratic features
Anxious and fearful
features
 paranoid
 schizoid
 schizotypal.
 Borderline
 Antisocial
 Narcissistic
 histrionic
 Avoidant
 Dependent
 Obsessive -
compulsive

7. ETIOLOGY
GENETIC FACTOR:
Cluster A personality disorders are more common in the
biological relatives of patients with schizophrenia than in
control groups
Antisocial personality disorder is associated with alcohol use
disorders
Depression is common in the family backgrounds of patients
with borderline personality disorder

8. A strong association is found between histrionic personality
disorder and somatization disorder
Patients with avoidant personality disorder often have high
anxiety levels
Patients with obsessive-compulsive personality disorder show
some signs associated with depression

9. BIOLOGICAL FACTORS:
Persons who exhibit impulsive traits also often show high levels of
testosterone, 17-estradiol, and estrone.
Low platelet MAO levels associated with more social activity.
Levels of 5-hydroxyindoleacetic acid (5-HIAA), a metabolite of
serotonin, are low in persons who attempt suicide and in patients
who are impulsive and aggressive.
 Slow-wave activity on EEGs in antisocial and borderline.

10. PSYCHODYNIMIC FACTORS:
Freudian explanations of arrested development at oral, anal,
and genital stages leading to dependent, obsessional, and
histrionic personalities; borderline personality organization.
Narcissistic and borderline personalities seen as displaying
primitive defense mechanisms such as splitting and
projective identification.

11. DEFENSE MECHANISMS
Personality Defense mechanism used
Borderline personality
disorder
Splitting, Projective-
identification
Paranoid personality
disorder
Projection
Schizoid personality disorder Withdrawal, Fantasy
Histrionic personality
disorder
Dissociation
Obsessive compulsive
personality disorder
Isolation

12. DSM-5 v/s ICD-10
(1) Schizotypal disorder is classified in the section on
schizophrenia
(2) Impulsive personality disorder is in ICD−10 but
not DSM, which instead includes intermittent explosive
disorder as an impulse control disorder separate from
personality disorder
(3) Narcissistic personality disorder is not included in
ICD−10
(4) Avoidance in DSM termed as Anxious and Obsessive–
compulsive as Anakastic.

13. SCALES
1. self-report questionnaires
2. semi structured interviews
SELF-REPORT QUESTIONNAIRES
Millon Clinical Multiaxial Inventory (MCMI; millon, 1982)
Contain 175 items. Take 25 minute to complete. Analysis by
computer.
Personality Diagnostic Questionnaire (PDQ-4+. Hyler et
al, 1990)

14. Minnesota Multiphasic Personality Inventory 2nd Edition
(MMPI; Hataway & Mckinley 1940)
Contain 550 statement. Asked pt to response on true false
or cannot say
Personality Assessment Inventory (PAI)
NEO-Personality Inventory
Consists of 250 self-rating items measured on 5 point likert
scale.

15. SEMI STRUCTURED INTERVIEWS:
International Personality Disorder Examination
Structured Clinical Interview for DSM-IV Axis II Disorders
(SCID-II and SCID-II-SQ)
Personality Assessment Schedule (PAS)

16. PARANOID PERSONALITY
DISORDERDIAGNOSTIC CRITERIA (DSM-5)
A. A pervasive distrust and suspiciousness of others such that
their motives are interpreted as malevolent, beginning by
early adulthood and present in a variety of contexts, as indicated
by four (or more) of the following:
1. Suspects, without sufficient basis, that others are exploiting,
harming, or deceiving him or her.
2. Is preoccupied with unjustified doubts about the loyalty or
trustworthiness of friends or associates.
3. Is reluctant to confide in others because of unwarranted fear
that the information will be used maliciously against him or her.

17. 4. Reads hidden demeaning or threatening meanings into benign
remarks or events.
5. Persistently bears grudges (i.e., is unforgiving of insults,
injuries, or slights).
6. Perceives attacks on his or her character or reputation that are
not apparent to others and is quick to react angrily or to counter
attack.
7. Has recurrent suspicions, without justification, regarding
fidelity of spouse or sexual partner
B. Does not occur exclusively during the course of schizophrenia, a
bipolar disorder or depressive disorder with psychotic features, or
another psychotic disorder and is not attributable to the
physiological effects of another medical condition.

18. Prevalence – 0.5-2.5% in general population
10-30% in psychiatric inpatients
2-10% in psychiatric outpatients.
More common in men than in women
Hallmarks are excessive suspiciousness and distrust of others
expressed as a pervasive tendency to interpret actions of others as
deliberately demeaning, malevolent, threatening, exploiting, or
deceiving.
Occupational and marital problems are common.

19. COMORBIDITY:
↑ risk of major depression
Obsessive-Compulsive Disorder, Agoraphobia, and Substance
Abuse or Dependence.
It postulated to be a premorbid antecedent of Delusional Disorder,
paranoid type.
FAMILIAL PATTERN AND GENETICS
↑ risk among relatives of probands with chronic Schizophrenia
and Delusional Disorder, paranoid type.

20. DIFFERENTIAL DIAGNOSIS:
delusional disorder
paranoid schizophrenia
borderline personality disorder

21. Schizotypal (which includes magical thinking, unusual perceptual
experiences, and oddities in speech, appearance, and
thought processes)
Obsessive-
Compulsive, Schizoid,
Borderline, and
Histrionic
(all with no prominent paranoid ideation)
Avoidant (which includes fear of embarrassment)
Antisocial (which includes personal gains in antisocial behavior)
Narcissistic (which includes fear of having “hidden” imperfections
and flaws revealed)

22. MANAGEMENT:
Psychotherapy is the treatment of choice
Pharmacotherapy is useful in dealing with agitation and
anxiety.
In most cases, an antianxiety agent such as diazepam suffices
Haloperidol to manage severe agitation or quasi-delusional
thinking.
Pimozide has successfully reduced paranoid ideation in some
patients.

23. SCHIZOID PERSONALITY
DISORDERA. A pervasive pattern of detachment from social relationships
and a restricted range of expression of emotions in
interpersonal settings, beginning by early adulthood and
present in a variety of contexts, as indicated by four (or more)
of the following:
1. Neither desires nor enjoys close relationships, including
being part of a family.
2. Almost always chooses solitary activities.
3. Has little, if any, interest in having sexual experiences with
another person.

24. 4. Takes pleasure in few, if any, activities.
5. Lacks close friends or confidants other than first-degree
relatives.
6. Appears indifferent to the praise or criticism of others.
7. Shows emotional coldness, detachment, or flattened affectivity.
B. Does not occur exclusively during the course of schizophrenia,
a bipolar disorder or depressive disorder with psychotic
features, another psychotic disorder, or autism spectrum
disorder and is not attributable to the physiological effects of
another medical condition.

25. Prevalence is about uncommon to 7.5% of the general population
More common in male
Solitary interests and success at noncompetitive, lonely jobs
that others find difficult to tolerate.
Lifelong inability to express anger directly
FAMILIAL PATTERN AND GENETICS
Increased prevalence among the relatives of probands with
Schizophrenia or Schizotypal Personality Disorder.

26. DIFFERENTIAL DIAGNOSIS
Schizophrenia, Delusional Disorder, and Affective Disorder with
Psychotic features
 Autistic Disorder
and Asperger's
Disorder
(severely impaired social interactions and
stereotypic Behaviors and interests in the latter two
disorders.)
Schizotypal (which includes magical thinking, unusual
perceptual experiences, AND oddities in speech,
appearance, and thought processes)
Avoidant (adequate emotionality in the latter, also social
isolation due to the fear of embarrassment, not to
indifference)

27. COURSE AND PROGNOSIS: occurs in early childhood or
adolescence. Long lasting
MANAGEMENT:
Same as paranoid personality disorder
Obsessive-Compulsive (adequate capacity for intimacy,
despite excessive isolation due to
perfectionism and workaholic
attitudes)
Paranoid Paranoid (which includes
suspiciousness, ideas of reference,
and guarded facade)

28. SCHIZOTYPAL
PERSONALITY DISORDER
(DSM-5)A. A pervasive pattern of social and interpersonal deficits
marked by acute discomfort with, and reduced capacity for, close
relationships as well as by cognitive or perceptual distortions and
eccentricities of behavior, beginning by early adulthood and present
in a variety of contexts, as indicated by five (or more) of the
following:
1. Ideas of reference (excluding delusions of reference).
2. Odd beliefs or magical thinking that influences behavior and
is inconsistent with subcultural norms (e.g., superstitiousness,
belief in clairvoyance, telepathy, or "sixth sense”: in children and
adolescents, bizarre fantasies or preoccupations).

29. 3. Unusual perceptual experiences, including bodily
illusions.
4. Odd thinking and speech (e.g., vague, circumstantial,
metaphorical, over elaborate,or stereotyped).
5. Suspiciousness or paranoid ideation..
6. Inappropriate or constricted affect.
7. Behavior or appearance that is odd, eccentric, or peculiar.

30. 8. Lack of close friends or confidants other than first-degree
relatives.
9. Excessive social anxiety that does not diminish with
familiarity and tends to be associated with paranoid fears
rather than negative judgments about self.
B. Does not occur exclusively during the course of
schizophrenia, a bipolar disorder or depressive disorder
with psychotic features, another psychotic disorder, or
autism spectrum disorder.

31. Diagnosis on the basis of the patients' peculiarities of thinking,
behavior, and appearance.
Increased prevalence of schizotypal features in the families of
schizophrenic patients
Frequently diagnosed in females with fragile X syndrome .
COMORBIDITY:
More than a half of these patients have had at least one episode
of Major Depression, and 30 to 50 percent have Major
Depression concurrent with this personality disorder.

32. 10% of schizotypal personality disorder eventually committed
suicide (T. McGlashan)
Occupational and social difficulties.
Prevalence rate of 3 percent in the general population
DIFFERENTIAL DIAGNOSIS:
Schizophrenia, Delusional Disorder, and Affective Disorder with
Psychotic features
Autistic Disorder, Asperger's
Disorder, and Expressive and
Mixed Receptive–Expressive
Language Disorder.
(more severely impaired social
interactions and stereotype
behaviors)

33. 
Schizoid and Paranoid (which rarely have magical thinking, unusual
perceptual experiences, or oddities in speech,
appearance, and thought processes)
Narcissistic (with a predominant sense of grandiosity, fragile
self-esteem, and fear of having “hidden”
imperfections or flaws revealed)
Avoidant (which rarely has oddities in appearance and
behavior, and in which fear of embarrassment, not
disinterest and detachment, causes social avoidance
and isolation)
Borderline (characterized by affective instability and stormy
relationships, as well as impulsive and manipulative
behavior)

34.  COURSE AND PROGNOSIS:
The schizotype is pre morbid personality of the pt. with schizophrenia
TREATMENT : psychotherapy and Antipsychotic medication
may be useful in dealing with ideas of reference, illusions, and
other symptoms of the disorder.