Personality disorders are enduring patterns of thinking, feeling and behaving that deviate from cultural norms and lead to distress or impairment. They are classified into three clusters - A (odd/eccentric), B (dramatic/erratic) and C (anxious/fearful). Specific disorders discussed include paranoid, schizoid and schizotypal PD from cluster A, antisocial, borderline, histrionic and narcissistic PD from cluster B, and avoidant, dependent and obsessive-compulsive PD from cluster C. Each disorder is defined by a set of diagnostic criteria and statistics on prevalence, etiology, course and treatment options are provided.

1. Personality Disorders

2. Personality Personality consists of enduring habitual patterns of thinking, feeling, behaving, relating and determine a person’s reaction to the two worlds, namely the inner psychological world and the outer environment.

3. What, then, is a personality disorder ?

4. DSM-IV-TR defines personality disorders as enduring subjective experiences and behavior that- deviate from cultural standards are rigidly pervasive have an onset in adolescence or early adulthood are stable throughout time lead to unhappiness and impairment

5. Classification Cluster A – Paranoid, Schizoid, Schizotypal Weird Cluster B – Antisocial, Borderline, Histrionic, Narcissistic Wild Cluster C – Avoidant, Dependent, Obsessive-Compulsive Wimpy

6. Prevalence - 10-18% Outpatient - 30-50% Inpatient > 50% 34% in alcohol abuse and anxiety disorders 48-65% among recurrent suicidal gestures Etiology Genetic Biological factors Environmental factors Psychoanalytic theories

7. Psychoanalytic Factors Sigmund Freud – personality traits are products of fixation at one psychosexual stage of development Wilhelm Reich – personality arose from the particular pattern of defense mechanisms - character armor

8. Defense Mechanisms The unconscious mental processes that the ego uses to resolve conflicts Flexible and adaptable Inflexible and rigid in personality disorders Ego-syntonic; a major reason why people with these disorders are reluctant to alter their behaviors

9. Defense Mechanisms Neurotic Introjection Identification Displacement Rationalization Repression Undoing Mature Humor Suppression Asceticism Altruism Anticipation Sublimation Primitive Projection Denial Dissociation Splitting Idealization Acting Out

10. Cluster A Personality Disorders WEIRD

11. 32 y/o male complaining of his girlfriend being untrustworthy Feels she is taking advantage of him Does not like her talking to 'friends' on the phone Feels people at work don't like him Lashed out at a stranger who was laughing loudly during a funny movie

12. “ Others are untrustworthy, and they try to take advantage of me”

13. Paranoid Personality Disorder SUSPECT (four of seven)‏ S pousal infidelity suspected U nforgiving S uspicious P erceives attacks E nemy or friend C onfiding in others feared T hreats perceived in benign events

14. Paranoid Personality Disorder 0.5-2.5% population, M > F, minorities, immigrants, deaf Course: Lifelong Differential Disorder: Delusional d/o, Schizophrenia, Schizoid PD, Avoidant PD Treatment: Psychotherapy Psychosis: Short term benzodiazepines and antipsychotics

15. 38 y/o single lab tech having difficulty being a 'team player.' Resents having to train new assistants Describes himself as a loner who feels awkward when forced into spending time with others. Can spend long hours by himself playing computer games. Prefers being alone; not distressed by it.

16. “ I prefer to be alone; my world is completely empty.”

17. Schizoid Personality Disorder DISTANT (four of seven)‏ D etached (flat) affect I ndifferent to criticism or praise S exual experiences of little interest T asks performed solitarily A bsence of close friends N either desires nor enjoys close relations T akes pleasure in few activites

18. Schizoid Personality Disorder 1-7.5% ;Males > Females 2:1 Higher incidence of psychotic disorder in relatives Onset in early childhood and remains throughout life Differential Diagnosis: Schizophrenia, Paranoid PD, OCPD, Avoidant PD Treatment: Supportive, Insight- oriented and sometimes group therapy No pharmacotherapy

19. 19 y/o college student presenting with long-standing worry of 'losing height.' Patient appeared disheveled and did not make eye contact. Frequently taps his nose to make a point. Doctor unable to establish rapport. Patient made some comments of a paranoid nature with sexual content.

20. “ I'd like to have friends but it's hard, because people find me pretty strange.”

21. Schizotypal Personality Disorder ME PECULIAR (five of ten)‏ M agical thinking or odd beliefs E xperiences unusual perceptions P aranoid ideation E ccentric behavior or appearance C onstricted (or inappropriate) affect U nusual thinking and speech L acks close friends I deas of reference A nxiety in social situations R ule out psychotic disorder

22. Schizotypal Personality Disorder 3% , males> females, biological relatives of schizophrenics Prognosis is guarded DD: Paranoid PD, Schizoid PD, Borderline PD, Avoidant PD, Schizophrenia Treatment: supportive therapy with social skills training Pharmacotherapy for brief periods of psychotic decompensation

23. Cluster B Personality Disorders WILD

24. 19 y/o male, comes in after encouragement from mother Appears intelligent, charming and funny Admits to several arrests for robbery, claims noble intentions Story does not pan out Extensive drug trafficking Has been stealing from mother No remorse

25. “ I love to take advantage of people, and I never feel bad about it.”

26. Antisocial Personality Disorder CORRUPT (three of seven)‏ C onformity to law is lacking O bligations ignored R eckless disregard for safety of self or others R emorse lacking U nderhanded P lanning insufficient (impulsive)‏ T emper

27. Antisocial Personality Disorder Prevalence: 3% M; <1% F 5 times more common in first degree relatives 75% of poor urban prisons Conduct disorder<15; comorbid ADHD, sub abuse DD:Borderline PD, Narcissistic PD, Bipolar disorder, Psychotic violence Very difficult to treat. Confined settings with external constraints BT with a strong emphasis on legal sanctions Pharmacotherapy for dangerous behavior

28. 45 y/o white female with a turbulent course in the clinic Has made suicide attempts in the clinic Abnormally strong attachment to previous resident Current resident feels disheartened, thinking they can never match up to standards Does not have children, therefore collects dolls Requires weekly sessions to prevent destabilization

29. “ I need people desperately, and fall apart completely when they reject me.”

30. Borderline Personality Disorder I DESPAIRR I dentity disturbance D isordered, unstable affect E mptiness- chronic feeling S uicidal behavior, gestures, or threats P aranoid ideation- transient, stress related A bandonment- tries to avoid I mpulsivity R age, inappropriate, intense R elationships- unstable, intense, extreme

31. Borderline Personality Disorder Prevalence:2-3% of population; 2:1 F:M ratio Increased prevalence of mood disorders in family members; mothers of patients also have BPD Diagnosed before 40 years, variable course DD: paranoid PD, histrionic PD, bipolar disease Treatment: Psychotherapy- exploratory, insight-oriented, supportive, CBT, DBT Medications for impulsivity, lability, psychosis, mood symptoms Be aware of Countertransference!

32. 31 year old WF discloses to her therapist that she loved to party in college Proud of the fact that she once slept with 12 different men at a party, including her 'best friend's ' boyfriend. Responds strongly to positive comments about her appearance. Sometimes vague and shallow with emotions. Easily influenced by TV, magazines and friends.

33. “ I'm an emotional and sexually charming person, and I need to be the center of attention!”

34. Histrionic Personality Disorder PRAISE ME (five of eight)‏ P rovocative behavior R elationships (considered more intimate than they are)‏ A ttention (likes to be center of)‏ I nfluenced easily S tyle of speech (impressionistic)‏ E motions (rapidly shifting, shallow)‏ M ade up E motions exaggerated

35. Histrionic Personality Disorder Prevalence: 2-3%, F>M Course is variable; comorbid somatization, dissociative, sexual and mood disorders. DD: Borderline PD, narcissistic PD, dependent PD, Somatization Individual psychodynamic psychotherapy with emotional clarification Benzos for transient emotional outbursts and anti-psychotics for dissociation and psychosis

36. 20 y/o male seen in clinic with 'impotence' States that he agreed to have sex with a platonic friend; extremely anxious about inability to perform Hates his job, 'they don't know what they're doing' Feels that his friends are petty, dating 'pretty but stupid women' Three years of therapy, never completes it

37. “ I'm talented and special, and I get angry and depressed when people don't recognize how great I am!”

38. Narcissistic Personality Disorder SPEEECIAL (five of nine)‏ S pecial P reoccupied with fantasies of success and power E nvious E ntitlement E xcessive admiration needed C onceited I nterpersonal exploitation A rrogant L acks empathy

39. Narcissistic Personality Disorder Prevalence:1%; 2-15% of clinical population Co-morbid mood disorders; severe mid-life crisis. DD: Borderline PD, Histrionic PD, Anti-social PD Treatment : Individual psychodynamic psychotherapy Insight-oriented psychotherapy Pharmacotherapy for depression and mood swings

40. Cluster C Personality Disorders WIMPY

41. 35 year old black male presents to unit after a suicide attempt Patient is in love with his neighbor of 10 years Tells the psychiatrist that he would attempt suicide again if she refused a date Admits to being shy Wants to be married and have children, and feels sad that this may never happen Often puts himself down during the interview

42. “ I'm really afraid of what people will think of me, so I avoid making new friends.”

43. Avoidant Personality Disorder CRINGES (four of seven)‏ C ertainty of being liked required R ejection -preoccupied with I ntimate relationships avoided N ew relationships avoided G ets around interpersonal contact E mbarrassment prevents new activities S elf viewed as inept, inferior

44. Avoidant Personality Disorder Prevalence:1-10%; temperament and disfiguring physical illnesses are predisposing factors, M=F Co-morbid mood d/o, anxiety d/o and social phobia DD: Schizoid PD, Dependent PD, Social phobia Course: Are able to function, marry and raise families as long as the environment is safe CBT Anxiolytics, MAOIs and SSRIs for anxiety and depression

45. 55 year old woman,married since she was 17, because she didn’t want to be alone Husband takes care of all the finances, and gives her a weekly allowance Worries excessively about making mistakes at her job and doesn’t want to be left alone at work Worried about teenage daughter who is in college- 'doesn't care anymore'.

46. “ I'm passive and dependent on others, and I go far out of my way to please those who are important to me.”

47. Dependent Personality Disorder RELIANCE (five of eight)‏ R eassurance required E xpressing disagreement difficult L ife responsibilities assumed by others I nitiating projects difficult A lone (feels helpless when alone)‏ N urturance (goes to lengths to get support)‏ C ompanionship sought urgently E xaggerated fears of being left to care for self

48. Dependent Personality Disorder Prevalence - 2.5% , F>M ,increased incidence in childhood separation anxiety DD: Avoidant PD, Borderline PD, Agoraphobia Course: co-morbid dysthymia, MDD, alcohol abuse; victims of emotional and physical abuse Treatment: Respond to individual psychotherapy, group therapy with stress on cognitive techniques, assertive training and social skills training Pharmacotherapy: Benzos and SSRIs

49. 41 y/o grocery store manager who describes herself as a 'micromanager' who likes to do things 'properly' Has trouble with employees because she constantly quadruple-checks everything they do Despite her insistence on perfection, her store is not doing well Divorced, because 'I had too much to do, I couldn't take care of him on top of it' Never has time for fun

50. “ I'm a perfectionist, I keep lists, drive myself hard, and I'm very serious about life.”

51. Obsessive-Compulsive Personality Disorder LAW FIRMS (four of eight)‏ L oses point of activity A bility to complete tasks compromised W orthless objects (unable to discard)‏ F riendships excluded (preoccupied with work)‏ I nflexible R eluctant to delegate M iserly S tubborn

52. Obsessive-Compulsive Personality disorder M>F, first degree relatives DD: Obsessive-Compulsive disorder, Narcissistic PD Course: Variable, few intimate long term relationships, may mellow with age. Depression, ETOH/ somatoform disorders Treatment: Patients often seek treatment on their own Group therapy , Benzos for anxiety

53. Personality Disorder NOS Persistent personality dysfunction that does not meet full criteria for a single PD, OR meets criteria for Appendix -B of DSM-IV-TR Passive aggressive PD Passive resistance to authority figures and to any request for adequate performance Depressive PD Pervasive pessimism, anhedonia, mirthlessness