Personality disorders

PERSONALITY
DISORDER
MR. JAYESH PATIDar
www.drjayespatidar.blogspot.com

• The DSM – IV – TR (American Psychiatric
Association, 2000) defines personality traits as
“Enduring patterns of perceiving, relating
to, & thinking about the environment & oneself
that are exhibited in a wide range of social &
personal contexts.”
www.drjayeshpatidar.blogspot.com

1. Paranoid Personality Disorder
2. Schizoid Personality Disorder
3. Schizotypal Personality Disorder
4. Antisocial Personality Disorder
5. Borderline Personality Disorder
6. Histrionic Personality Disorder
7. Narcissistic Personality Disorder
8. Avoidance Personality Disorder
9. Dependent Personality Disorder
10. Obsessive-compulsive Personality
Disorder
11. Passive-aggressive Personality
Disorder

The DSM-IV-TR defines paranoid
personality disorder as “a pervasive distrust &
suspiciousness of others such that their
motives are interpreted as
malevolent, beginning by early adulthood &
present in a variety of contexts” (APA, 2000).

The prevalence of paranoid
personality disorders is estimated at 0.5%
to2.5% of the general population, it’s more
common in males.

The hallmarks of paranoid personality disorder are
suspicion & distrust of others’ motives. Other features
include:
Refusal to confide in others
Inability to collaborate with others
Hypersensitivity
Inability to relax (hypervigilance)
Self-righteousness
Detachment & social isolation
Poor self – image
Sullenness, hostility, coldness & detachment
Humorlessness
Anger, jealousy & envy
Bad temper, hyperactivity & irritability
Lack of social support systems.

• The specific cause of paranoid personality
disorder is unknown. Its higher incidence in
families with a schizophrenic member suggests a
possible genetic influence.
• Some expert believe that the disorder result
(at least partly) from negative childhood
experiences & a threatening domestic atmosphere
– for example, extreme unfounded rage or
condescension by the parents, which can produce
profound insecurity in the child.

Schizoid personality disorder is
characterized primarily by a profound defect
in the ability to form personal relationships or
to respond to others in any meaningful,
emotional way (Phillips, Yen, & Gunderson,
2003). These individual displays a lifelong
pattern of social withdrawal & their
discomfort with human interaction is very
apparent.

Epidemiological Statistics:-
The prevalence of schizoid
personality disorder within general population
has been estimated at between 3 & 7.5%. it is
diagnosed more frequently in men.

Clinical Features
• Emotional detachment
• Inability to experience pleasure
• Lack of strong emotions & little observable change in mood
• Avoidance of activities that involve significant interpersonal
contact
• Little desire for or enjoyment of close relationships
• No desire to be part of a family
• Strong preference for solitary activities
• Little or no interest in sexual experiences with another person
• Lack of close friends or confidants other than immediate
family members
• Shyness, distrust & discomfort with intimacy
• feeling of superiority
• loneliness
• self-consciousness
• Oversensitivity to slights.www.drjayeshpatidar.blogspot.com

Predisposing Factors
As with the other personality disorders,
the exact cause of schizoid personality disorder
isn’t known. Some researchers think it may be
inherited. Other possible causes may include:
A sustained history of isolation during
infancy & childhood
Cold or grossly deficient early parenting
Parental modeling of interpersonal
withdrawal, indifference, & detachment.

SCHIZOTYPAL PERSONALITY DISORDER

EPIDEMIOLOGICAL STATISTICS:-
SCHIZOTYPAL PERSONALITY
DISORDER IS FOUND IN ABOUT 3% OF THE
GENERAL POPULATION. IT’S SLIGHTLY MORE
COMMON IN MEN THAN IN WOMEN.
Definition:-
Schizotypal personality disorder is marked
by a pervasive pattern of social & interpersonal
deficits, along with acute discomfort with others.
People with this disorder have odd thought &
behavioural patterns.

• Odd or eccentric behaviour or appearance
• Inaccurate beliefs that other’s behaviour or environmental
phenomena are meant to have an effect on the patient
• Odd beliefs or magical thinking (such as thinking that one’s
thought or desires can influence the environment or cause
events to occur)
• Unusual perceptual experiences, including bodily illusions
• Vague, circumstantiallty, or stereotypical speech or thinking
• Unfounded suspicious of being followed, talked about,
persecuted, or under surveillance
• Inappropriate or constricted affect
• Lack of close relationships other than immediate family
members
• Social isolation
• Excessive social anxiety
• A sense of feeling different & not fitting in with others easily

Predisposing Factors:-
Schizotypal personality disorder may have a genetic basis. Family,
twin & adoption studies show an increased risk of the condition in
people with a family history of schizophrenia. Environmental factors
(such as severe stress) may determine whether schizotypal
personality disorder or schizophrenia manifests.
Dopamine Deviance: Some evidence suggests that patients with
schizotypal personality disorder have poor regulation of dopamine
pathways in the brain.
Psychological & Cognitive theories: psychological & cognitive
explanations for schizotypal personality disorder focus on deficits in
attention & information processing. These patients perform poorly on
tests that assess continuous performance tasks, which require the
ability to maintain attention on one object & to look at new stimuli
selectively.
Psychoanalytic theories: One proposes that patients with this
disorder have ego boundary problems; the other, that these patients
were raised by patients with inadequate parenting skills, poor
communication skills & loose association of words.www.drjayeshpatidar.blogspot.com

ANTISOCIAL PERSONALITY DISORDER

Definition:-
The highlight of antisocial personality disorder
is chronic antisocial behaviour that violates other’s
rights or generally accepted social norms. This
disorder predisposes a person toward criminal
behaviour.
In the general population, the prevalence of
antisocial personality disorder is about 2% to 3%.
Roughly one-half of people with this disorder have a
history of arrest. It affects three to four times as
many males than females.

Clinical Features:-
A patient with antisocial personality disorder has a long-standing pattern
of disregarding other’s right & society’s values. Other assessment
finding may include:
• Repeatedly performing unlawful acts
• Reckless disregard for his own or others’ safety
• Deceitfulness
• Lack of remorse
• Consistent irresponsibility
• Power-seeking behaviour
• Destructive tendencies
• Impulsivity & failure to plan ahead
• Superficial charm
• Manipulative nature
• Inflated, arrogant self-appraisal
• Irritability & aggressiveness
• Inability to maintain close personal or sexual relationships
• Disconnection between feelings & behaviours
• Substance abuse

Predisposing Factors:-
Genetic & biological factors may influence the development of antisocial
personality disorder. Biological factors include:
 Poor serotonin regulation in certain brain regions, which may decrease
behavioural inhibition.
 Reduce autonomic activity & developmental or acquired abnormalities in the
prefronatal brain systems.
• Such biological factors may underlie the low arousal, poor fear
conditioning & decision-making deficits seen in patients with
antisocial personality disorder.
Children at risk
• Other possible causes or risk factors include attention deficit
hyperactivity disorder, large families & childhood exposure to these
conditions:
 Substance abuse
 Criminal behaviour
 Physical or sexual abuse
 Neglectful or unstable parenting
 Social isolation
 Transient friendships
 Low socioeconomic status

A disorder of poor regulation of emotions,
borderline personality disorder is marked by a
pattern of instability in interpersonal
relationships, mood, behaviour & self image.
Although people with this disorder may
experience it in various ways, most find it hard to
distinguish reality from their own misperceptions
of the world. Their emotions overwhelm their
cognitive functioning, creating many conflicts
with others.

The prevalence of borderline personality disorder affects 2% to
3% of the general population, about 11% of psychiatric outpatients, &
nearly 20% of psychiatric inpatients. It’s three times more common in
females than in males.
Clinical Features:-
Major signs & symptoms of borderline personality disorder fall
into four main categories – unstable relationships, unstable self-
image, unstable emotions, & impulsivity. Symptoms are more acute
when the patient feels isolated & without social support.
Assessment findings may include:
• A pattern of unstable & intense interpersonal relationships
• Splitting (viewing others as either extremely good or extremely bad)
• Intense fear of abandonment, as displayed in clinging & distancing
maneuvers
• Rapidly shifting attitudes about friends & loved ones
• Desperate attempts to maintain relationships

Unstable perceptions of relationships
Manipulation, as in pitting people against one another
Limited coping skills
Dissociation (separating objects from their emotional significance)
Transient, stress-related paranoid ideation or severe dissociative symptoms
Inability to develop a healthy sense of oneself
Uncertainty about major issues, such as self-image, identity, life goals, sexual
orientation, values, career choices or types of friends
Imitative behaviour
Rapid, dramatic mood swings, from euphoria to intense anxiety to rage,
within hours or days
Acting out of feelings instead of expressing them appropriately or verbally
Inappropriate, intense anger or difficulty controlling anger
Chronic feelings of emptiness
Unpredictable self-damaging behaviour, such as driving dangerously,
gambling, sexual promiscuity, overeating, spending & abusing substances
Self-destructive behaviour, such as physical fights, recurrent accidents, self-
mutilation & suicidal gestures

The precise causes of borderline personality
disorder are unknown, but several theories are being
investigated. Because it’s five time more common in
first-degree relatives of people who have it,
researchers suspect genetic may play a role.
Biological factors may involve:
• Dysfunction in the brain’s limbic system or frontal lobe
• Decreased serotonin activity
• Increased activity in alpha-2-noradrenergic receptors.
• Early losses & abuse:-
Prolonged separation from their parents, other
major losses early in life, & physical, sexual, or
emotional abuse or neglect seem to be more common
in patients with this disorder than in the general
population.

Definition:-
This disorder is characterized by
colorful, dramatic, & extroverted behaviour in
excitable, emotional people. They have difficulty
maintaining long-lasting relationships, although
they require constant affirmation of approval &
acceptance from others.
The prevalence of the disorder is thought to be
about 2 to 3%, & it is more common in women
than in men.

Assessment of a patient with histrionic personality
disorder may reveal:
• Constant craving for attention, stimulation, & excitement
• Intense affect
• Shallow, rapidly shifting expression of emotions
• Flirting & seductive behaviour
• Overinvestment in appearance
• Exaggerated, vague speech
• Self-dramatization
• Impulsivity
• Exhibitionism
• Suggestibility & impressionability
• Egocentricity, self-indulgence, & lack of consideration for others
• Intolerance of frustration, disappointment, & delayed
gratification

Somatic (physical) preoccupations & symptoms
Angry outbursts & tantrums
Sudden enraged, despairing, or fearful states
Intense anger toward people viewed as withholding
Divisive, manipulative behaviour
Intolerance of being alone
Suppression or denial of internal distress, weakness,
depression or hostility
Dread of growing old
Demanding & manipulative nature
Use of alcohol or drugs to quickly alter negative feelings
Depression
Suicidal gestures & threats.

• The cause of histrionic personality disorder
isn’t known. A genetic component may be
involved, as hysterical traits are more common
in relatives of those with this disorder.
However, little research has been done on the
biological origins of this disorder.
• Childhood events may come into play as
well. Psychoanalytic theories focus on
seductive & authoritarian attitudes by fathers
of these patients.

Definition:-
Persons with narcissistic personality disorder
have an exaggerated sense of self-worth. They lack
empathy, & are hypersensitive to the evaluation of
others. They believe that they have the inalienable
right to receive special consideration & that their
desire is justification for possessing whatever they
seek.
Narcissistic personality disorder is found in less
than 1% of the general population. It affects about
three times as many males as females.www.drjayeshpatidar.blogspot.com

In a patient with narcissistic personality
disorder, assessment finding may include:
• Arrogance or naughtiness
• Self-centeredness
• Unreasonable expectations of favorable treatment
• Grandiose sense of self-importance
• Exaggeration of achievements & talents
• Preoccupation with fantasies of
success, power, beauty, brilliance or ideal love
• Manipulative behaviour
• Constant desire for attention & admiration
• Lack of empathy
• Lack of concern over whom he offends
• Taking advantage of others to achieve his own goals
• Rage, shame or humiliation in response to criticism

 The exact cause of narcissistic personality disorder is
unknown. A psychodynamic theory purposes that it
arises when a child’s basic needs go unmet.
 Love thyself, hate thyself:
• Another theory holds that patients with this
disorder have an ambivalent self-perception: an
idealized (or overidealized) view of the self coexists
with deep feelings of inferiority & low self-esteem.
Thus, the grandiose image is an effort to cover
feelings of inferiority.
• According to this theory, the patient received
little encouragement & support from his parents
during childhood & tends to internalize the process
by looking for these feelings within him-self.

Definition:-
Avoidant personality disorder is marked by
feelings of inadequacy, extreme social
anxiety, social withdrawal, & hypersensitivity to
other’s opinions. People with this disorder have low
self-esteem & poor self-confidence. They dwell on
the negative & have difficulty viewing situations &
interactions objectively.
The prevalence of the disorder in the
general population is between 0.5 & 1%, & it
appears to be equally common in men & women.www.drjayeshpatidar.blogspot.com

A patient with avoidant personality disorder may exhibit or report:
Shyness, timidity, & social withdrawal
Behaviour or appearance that’s meant to drive others away (which gives him
a sense of control)
overtalkativeness
Constant mistrust or wariness of others
Testing of others’ sincerity
Difficulty starting & maintaining relationships
Perfectionism
Rejection of people who don’t live up his impossibly high standards
Limited emotional expression
Tenseness & anxiety
Low self-esteem
Feelings of being unworthy of successful relationships
Self-consciousness
Loneliness
Reluctance to take personal risks or engage in new activities
Frequent escapes into fantasy, such as by excessive reading, watching TV, or
daydreaming.

Avoidant personality disorder most likely results from a
combination of genetic, biological, environmental, & other
factors – although the evidence for genetic & biological causes
is weak. From a psychodynamic view, the disorder has been
attributed to an overly critical parental style
• Avoidant personality disorder is closely linked to
temperament. Studies of children under age 2 found that
some have an apparently inborn tendency to withdraw
from new situation or people. In fact, roughly 10% of
toddlers are habitually fearful & withdrawn when exposed
to new people & situation. Some evidence suggests that a
timid temperament in infancy may predispose a person to
developing avoidant personality disorder later in life.

- Information overload: The inherited tendency to be shy
may result from overstimulation or an excess of
incoming information. The patient cant’s cope with the
excess information & withdraws in defense. Inability to
cope with the information overload may stem from a
low autonomic arousal threshold.
- Low threshold, grater response: Research suggests that
in people with this disorder, certain structures in the
brain’s limbic system may have a lower threshold of
arousal & a more pronounced response when activated.
• Some expert believe that significant environmental
influences during childhood, such as rejections or
peers, leads to the full development of avoidant
personality disorder.

Dependent personality disorder is
characterized by “a pervasive & excessive need
to be taken care of that leads to submissive &
clinging behaviour & fear of separation”.
In the general population, its prevalence is
about 1.5%. it affects slightly more females
than males.

Assessment findings in a patient with dependent personality
disorder may include:
Submissiveness
Self-effacing, apologetic manner
Low self-esteem
Lack of self-confidence
Lack of initiative
Incompetence & a need for constant assistance
Intense, unremitting need to be loved in a stable longterm
relationship that goes through minimal change
Anxiety & insecurity, especially when deprived of a
significant relationship
Feelings of inferiority, & unworthiness
Hypersensitivity to criticism

• In females, little need to overtly control or
complete with others
• Demanding behaviour
• Use of cajolery, bribery, promises to change, &
even threats to maintain key relationships
• Fear & anxiety over losing a relationship or being
alone
• Dependence on a number of people, any one of
whom could substitute for the other
• Difficulty making everyday decisions without
advice & reassurance
• Avoidance of change & new situations
• Exaggerated fear of losing support & approval.

 The exact cause of dependent personality disorder isn’t
known. Because it tends to run in families, it may involve a
genetic component.
 According to some expert, authoritarian or overprotective
parenting may lead to high levels of dependency. These
parenting styles may cause the child to believe that she
can’t function without other’s guidance & protection & that
the way to maintain relationships is to give in to others’
demand
 Possible contributing factors may include:
- Childhood trauma
- Closed family system that discourages outside relationships
- Childhood physical or sexual abuse
- Social isolation

OBSESSIVE – COMPUSIVE PERSONALITY DISORDER

Individual with obsessive –compulsive
personality disorder are very serious & formal &
have difficulty expressing emotions. They are overly
disciplined, perfectionistic, & preoccupied with
rules. They are inflexible about the way in which
things must be done & have a devotion to
productivity to the exclusion of personal pleasure.
The prevalence of the disorder in the general
population is 1.5%, - about twice as many males as
females. www.drjayeshpatidar.blogspot.com

A patient with obsessive-compulsive personality disorder may describe
his symptoms in a logical way, attaching little emotion to any physical
discomfort. Assessment findings commonly include:
• Behavioural, emotional, & cognitive rigidity
• Perfectionism
• Severe self-criticism
• Indecisiveness
• Controlling manner
• Difficulty expressing tender feelings
• Poor sense of humor
• Cool, distant, formal manner
• Emotional constriction
• Excessive discipline
• Aggression, competitiveness, & impatience
• Bouts of intense anger when things stray from the patient’s idea of
how things “should be”

• Difficulty incorporating new information into his life
• Psychosomatic complaints
• Hypochondriasis
• Sexual dysfunction
• Chronic sense of time pressure & inability to relax
• Indirect expression of anger despite an apparent
undercurrent of hostility
• hoarding of memory & other possessions
• Preoccupation with orderliness, neatness &
cleanliness
• Discuss about morality, ethics or values
• Signs & symptoms of depression
• Physical complaints (commonly stemming from
overwork).

• Genetic & developmental factors may
play a role in the development of this
disorder. A twin & adoption study suggests
that it runs in families.
• Psychodynamic theories view the patient
as needing control as a defense against
feelings of powerlessness or shame.

Definition:-
The DSM-IV-TR defines this disorder
as a pervasive pattern of negativistic attitudes
& passive resistance to demands for adequate
performance in social & occupational
situations that begins by early adulthood &
occurs in a variety of contexts.

Features:-
• Feels cheated & unappreciated
• Passively resists fulfilling routine social & occupational tasks
• Complains of being misunderstood & unappreciated by
others
• Argumentative
• Unreasonably criticizes & scorns authority
• Expresses envy & resentment toward those apparently
more fortunate
• Voices exaggerated & persistent complaints of personal
misfortune.
• Alternates between hostile defiance & contrition

Contradictory parental attitude &
behaviour are implicated in the predisposing
to passive-aggressive personality disorder.
Through this type of
environment, children learn to control their
anger for fear of provoking parental
withdrawal & not receiving love & support –
even on an inconsistent basis. Overtly the
child appears polite & undemanding; hostility
& inefficiency are manifested only covertly &
indirectly. www.drjayeshpatidar.blogspot.com

Most clinicians
believe it best to strive for
lessening the inflexibility of
the maladaptive traits &
reducing their interference
with everyday functioning
& meaningful relationship.
Selection of intervention is
generally based on the
area of greatest
dysfunction, such as
cognitive, affect, behaviour
or interpersonal relations.

 Interpersonal psychotherapy may be particularly
appropriate because personality disorders largely reflect
problems in interpersonal style. Long-term psychotherapy
attempts to understand & modify the maladjusted
behaviours, cognition, & affects of clients with personality
disorders that dominate their personal lives &
relationships.
 The core element of treatment is the establishment
of an empathic therapist-client relationship, based on
collaboration & guided discovery in which the therapist
functions as a role model for the client.
 Interpersonal psychotherapy is suggested for clients
with
paranoid, schizoid, schizotypal, borderline, dependent, nar
cissistic, & obsessive-compulsive personality disorders

The treatment of choice for
individuals with histrionic personality disorder
has been psychoanalytical psychotherapy.
Treatment focuses on the unconscious
motivation for seeking total satisfaction from
others & for being unable to commit oneself
to a stable, meaningful relationship.

 This treatment is especially appropriate for
individuals with antisocial personality disorder,
who respond more adaptively to support &
feedback from peers. In milieu or group therapy,
feedback from peers is more effective than in
one-to-one interaction with a therapist.
 Group therapy – particularly homogeneous
supportive groups that emphasize the
development of social skills – may be helpful in
overcoming social anxiety & developing
interpersonal trust & rapport in clients with
avoidant personality disorder.

 Behavioural strategies offer reinforcement
for positive change. Social skills training &
assertiveness training teach alternative ways
to deal with frustration.
 Cognitive strategies help the client
recognize & correct inaccurate internal mental
schemata.
 This type of therapy may be useful for
clients with obsessive-compulsive, passive-
aggressive, antisocial, & avoidant personality
disorders.

Drugs have no effect in the treatment of the disorder
itself, some symptomatic relief can be achieved
• Antipsychotic medications are helpful in the treatment of
psychotic decompensation experienced by clients with
paranoid, schizotypal, & borderline personality disorder.
Antipsychotic have resulted in improvement in illusions,
ideas of reference, paranoid thinking, anxiety & hostility in
some clients.
• The selective serotonin reuptake inhibitors (SSRIs) &
monoamine oxidase inhibitors (MAOIs) have been
successful in decreasing impulsivity & self-destructive acts
in the clients with borderline personality disorder.
• Lithium carbonate & propranolol (Inderal) may be useful for
the violent episodes observed in the clients with antisocial
personality disorder.
• Anxiolytics are useful for clients with avoidant personality
disorder

1. R/t rage reactions, negative
role-modeling, and inability to tolerate frustration.
• Convey an accepting attitude towards this client. Work on
development of trust, keep all promises & convey the
message that it is not him or her but the behaviour that is
unacceptable.
• Maintain low level of stimuli in client’s environment (low
lighting, few people, simple décor, low noise level).
• Observe client’s behaviour frequently during routine
activities & interactions, avoid appearing watchful &
suspicious.
• Remove all dangerous objects from client’s environment.

Help client identify the true object of his or her
hostility.
Encourage client to verbalize hostile feelings
gradually.
Explore with client alternative ways of handling
frustration.
Staff should maintain & convey a calm attitude.
Administer tranquilizing medications as ordered by
physician or obtain an order if necessary. Monitor
for effectiveness & for adverse side effects.
If client is not calmed by “talking down” or by
medication, use of mechanical restraints may be
necessary.

R/t dysfunctional family
system, evidenced by disregards for societal norms
& laws, absence of guilty feelings, or inability to
delay gratification.
• From the onset, client should be made aware of
which behaviour are acceptable & which are not.
Explain consequences of violation of the limits.
• Do not attempt to coax or convince client to do the
“right thing.” Do not use the words “you should (or
shouldn’t)….”,
• Provide positive feedback or reward for acceptable
behaviours.

• Being to increase the length of time requirement
for acceptable behaviour in order to achieve the
reward.
• A milieu unit provides the appropriate
environment for the client with antisocial
personality.
• Help client to gain insight into his or her own
behaviours.
• Talk about past behaviours with client. Discuss
behaviours that are acceptable by society & those
which are not.
• Throughout relationship with client, maintain
attitude of “It is not you, but your behaviour, that
is unacceptable.”

3. Chronic low self-esteem R/t repeated negative
feedback resulting in diminished self-
worth, evidenced by manipulation of others to
fulfill own desires or inability to form
close, personal relationships.
4. Impaired social interaction R/t to negative role
modeling & low self-esteem, evidenced by inability
to develop a satisfactory, enduring, intimate
relationship with another.
5. Deficient knowledge (self-care activities to achieve
& maintain optimal wellness) R/t lack of interest in
learning & denial of need for
information, evidenced by demonstration of
inability to take responsibility for meeting basic
health practices. www.drjayeshpatidar.blogspot.com

THANK YOUwww.drjayeshpatidar.blogspot.com

Personality disorders

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