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PERSONALITY DISORDER
Prepared By:
Mofeeda Nadi
Arina Hairin
Ajeerah Mustaffa
Definition
 Deeply ingrained, maladaptive patterns of behaviour; recognisable in adolescence or earlier; continuing
throughout most of adult life; either the patient or others have suffer; there is an adverse effect on the individual
or society.
 Epidemiology
•
More commonly diagnosed in:
 Age group 18-35
 Male sex
 Lower social class
 International prevalence is 6%.
General principles of personality disorders
• Less of a disorder, more of an enduring set of behavioral trait (axis II).
• degree of maladaptiveness/ difficult interactions over the long term.
• Egosyntonic
• Diverse ,idiopathic
• May predispose patient to various comorbid psychiatric disorders.
• CBT and insight-oriented psychotherapy are always the treatment of
choice (absent comorbid mood /anxiety/psychotic symptoms).
Diagnosis and DSM-IV criteria
• 1- pattern of behavior/inner experience that deviate from the person’s
culture and is manifested in 2 or more of the following ways (CAPRI):
Cognition.
Affect.
Personal Relation.
Impulse control.
2. The pattern:
Is pervasive and inflexible with a broad range of situations.
Is stable and has onset no later than adolescence or early adulthood.
Lead to significant distress in functioning.
Not accounted for by another mental or medical illness, or by use of
substance.
Clusters
 Cluster A : (odd, eccentric)

Paranoid personality disorder

Schizoid personality disorder

Schizotypal personality disorder
 Cluster B : (dramatic, emotional)

Antisocial personality disorder

Borderline personality disorder

Histrionic personality disorder

Narcissistic personality disorder

Cluster C : (anxious, fearful)

Avoidant personality disorder

Dependent personality disorder

Obsessive-compulsive personality disorder
Cluster A
• Paranoid personality disorder
• Schizoid personality disorder
• Schizotypal personality disorder
Paranoid personality disorder (PPD)
Long standing mistrust and suspicion of others, deep cynicism, slow to
forgive, They seem to be angry and hostile.
They tend to be pathologically jealous. e.g. Unfaithful partner.
• Often they have schizoid features like isolation, because of suspicion of
others.
• Difficulty making new friends may result in small network of support,
increasing risk of comorbid MDD.
• May worsen with age.
• During sever stress or psychologically traumatic events, may develop sx
of psychosis.
• Differential includes
- Delusional disorder, persecutory type-DD will tend to center
around a specific delusion, whereas Paranoid PD will be more
generalized.
-schizophreniform disorder / schizophrenia – psychotic and or
disorganized thinking.
Clinical example
• A 30 year old man says his wife has been cheating on him because he
does not have a good enough job to provide for her needs. He also
claims that on his previous job, his boss laid him off because he did a
better job than his boss. Refuses couples therapy because he believe
that treater will side with his wife. Believes neighbors are critical of him.
Paranoid personality disorder
• Diagnosis and DSM IV criteria:
 Diagnosis requires a general distrust of others, beginning by early adulthood.
 At least four of the following must also be present for diagnosis.
① Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them.
② Preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
③ Reluctant to confide in others because of unwarranted fear that the information will be used
maliciously against him or her.
④ Interpretation of benign remarks or events hidden demeaning or
threatening meanings.
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 counterattack.
④ Has recurrent suspicions, without justification, regarding fidelity of spouse
or sexual partner
Paranoid personality disorder
• Epidemiology
 Prevalence: 0.5-2.5%.
 Male>Female.
 HIGH incidence in Family members of schizophrenics.
Paranoid personality disorder
• Prognosis and treatment
 Some patient with PPD may eventually be diagnosed with schizophrenia
 The disorder has a chronic life long course, causing marital and work related problems.
 Psychotherapy is the treatment of choice.
 Short course anti anxiety and anti psychotics may be beneficial for transient psychosis
Schizoid Personality Disorder
• Loners: extreme introversion ; prefer isolation; reduced/blunted affect;
limited desire for friends or relationships, decreased emotional
understanding.
• Less common
• Differential includes:
-social anxiety disorder – patients with SAD will want to have social
interactions , but are fearful due to possible embarrassment and anxiety.
- avoidant PD – also will desire social interaction, but are fearful due to
perceived inferiority.
- schizotypal PD – don’t have eccentric or magical thinking or odd
perception, thought, and behavior.
-paranoid schizophrenia – don’t have any fixed delusion.
Clinical case
• A 45 year old scientist works in the lab most of the day and has no
friends. He has not been able to keep his job because of failure to
interact with his coworkers. He expresses no desire to make friends.
Schizoid Personality Disorder
• Diagnosis and DSM IV criteria:
A pattern of voluntary social withdrawal and restricted range of emotional
expression, beginning of early adulthood.
Four or more of the following must be present.
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 activity with another person
Schizoid Personality Disorder
④Takes pleasure in few activities
⑤Lacks close friends or confidants other than first-degree relatives
⑥Appears indifferent to praise or criticism.
⑦Shows emotional coldness, detachment, or flattened affectivity.
Schizoid Personality Disorder
• Epidemiology
 Prevalence : 7%.
 Prevalence in Men is twice that of female.
 Family history of schizophrenia is not related to SPD.
Schizoid Personality Disorder
• Prognosis and treatment
 Usually chronic course but not always lifelong.
 Psychotherapy is the treatment of choice.
 Short course antipsychotics for transient psychosis.
Schizotypal Personality Disorder
• Odd thoughts, behavior, appearance; magical thinking; superstitious; social
anxiety/isolation
• Thoughts may be borderline bizzare/delusional, but thought process is coherent
• During severe stress or psychologically traumatic events, may develop sx of
psychosis
• Schizophrenia spectrum
• Differential includes:
-schizophreniform disorder/ schizophrenia – psychotic thoughts will be most
prominent. Much lesser degree of function.
-social anxiety disorder - Schizotypal PD will be more of actual fear of people,
whereas SAD is a fear of embarrassment around people
-schizoid PD – will not display the odd thoughts and behavior
Clinical example
• a 35 year old man dresses in a space suit every Tuesday and Thursday.
He has computers in his basement to “detect the precise time of alien
invasion”. He has no evidence of auditory or visual hallucination.
Schizotypal Personality Disorder
• Diagnosis and DSM IV criteria:
 A pattern of social deficits marked by eccentric behavior, cognitive or
perceptual distortion, and discomfort with close relationships, beginning
by early adulthood.
 Five or more of the following must be present.
Schizotypal Personality Disorder
① Ideas of reference (excluding delusions of reference)
② Odd beliefs or magical thinking that influences behavior and is inconsistent with sub cultural norms.
③ Unusual perceptual experiences, including bodily illusions.
④ Suspiciousness or paranoid ideation.
⑤
Inappropriate or constricted affect
⑥ Behavior or appearance that is odd, eccentric, or peculiar
⑦
Lack of close friends or confidants other than first-degree relatives
⑧ Excessive social anxiety
Schizotypal Personality Disorder
• Prognosis and treatment
 This disorder is chronic and patient eventually develop schizophrenia.
 Psychotherapy is the treatment of choice.
 Short course of low dose antipsychotics to decrease social anxiety.
• Epidemiology
 Prevalence: 3%.
DIAGNOSIS AND DSM-IV CRITERIA
• Pattern of disregard for others and violation of the rights of others since
age 15.
• Patients must be at least 18 years old for this diagnosis; history of behavior
as child/adolescent must be consistent with conduct disorder.
• Three or more of these criteria:
-Failure to conform to social norms by committing unlawful acts
-Deceitfulness/repeated lying/manipulating others for personal gain
- Impulsivity/failure to plan ahead
- Irritability and aggressiveness/repeated fights or assaults
-Recklessness and disregard for safety of self or others
-Irresponsibility/failure to sustain work or honor financial obligations
-Lack of remorse for actions
CHARACTERISTICS
• Those with antisocial personality disorder tend to antagonize,
manipulate or treat others harshly.
• They may often violate the law, get into trouble, yet they show no
guilt or remorse.
• They may lie, behave violently or impulsively, and have problems with
drug and alcohol use.
• These characteristics typically make people with antisocial personality
disorder unable to fulfill responsibilities related to family, work or
school.
• Begins in childhood as conduct disorder
• They are skilled at reading social cues and appear charming or normal
to others who meet them for the first time.
• 3% in men, 1% in women
• Higher incidence in poor urban areas & prisoners
• 5x higher risk in 1st degree relatives
• DDX : Drug abuse
• Prognosis :
• Chronic but symptoms improve as age increase
• Many patients have multiple somatic complaints, substance abuse, major
depression
Treatment :
Best Choice – dialectical behavior therapy (DBT) & behavioral therapy
Psychotherapy is ineffective
Pharmacotherapy use to treat symptoms but BE AWARE to high addictive
potential to the patient
CHARACTERISTICS OF BPD
Patient suffer from :
-problems with regulating emotions/ thoughts
- impulsive and reckless behavior
- unstable relationship with other people
CHARACTERISTICS OF BPD (DSM4)
I –impulsive
M- moody
P – paranoid under stress
U – unstable self image
L – labile, intense relationship
S – suicidal
I – inappropriate anger
V – vulnerable to abandonment
E - emptiness
BORDERLINE
PROGNOSIS:
EPIDEMIOLOGY
Prevalence : 1-2%
F:M, 2:1
Suicide rate 10%
- stable, chronic
course
- high incidence of
coexisting major
depression and/or
substance abuse
- high risk of suicide
TREATMENT:
DDX :
schizophrenia
& bipolar 2
-psychotherapy
-pharmacotherapy
HISTRIONIC
PERSONALITY DISORDER
DIAGNOSIS AND DSM-IV CRITERIA
• 1) Uncomfortable when not the center of attention
• 2) Inappropriately seductive or provocative behavior
• 3) Uses physical appearance to draw attention to self
• 4) Has speech that is impressionistic and lacking in details
• 5) Theatrical and exaggerated expression of emotion
• 6) Easily influenced by others or situation
• 7) Perceives relationships as more intimate than they actually are
** At least 5/7
HISTRIONIC
EPIDEMIOLOGY
PROGNOSIS :
Prevalence : 2-3%
- chronic
Women > Men
-symptoms improve as
increase in age
TREATMENT:
DDX
-PSYCHOTHERAPY
-Borderline
personality disorder
-PHARMACOTHERAPY
DIAGNOSIS AND DSM-IV CRITERIA
Five or more of the following must be present:
 Exaggerated sense of self-importance
 Preoccupation with fantasies of unlimited money, success, brilliance, etc
 Believes that he/she is special or unique and can associate only with high status
individuals
 Needs excessive admiration
 Has sense of entitlement
 Takes advantage of others for self gain
 Lacks empathy
 Envious of others or believes others are envious of him/her
 Arrogant or haughty
• However, these patients often have fragile self esteem
NARCISSISTIC
PROGNOSIS:
EPIDEMIOLOGY
- chronic
Prevalence <1%
- higher incidence of
depression & midlife
crises
DDX :
TREATMENT:
Antisocial personality
disorder
- Psychotherapy
- Pharmacotherapy :
antidepressant/lithium
CLUSTER C
Avoidant
personality
disorder
dependant
personality
disorder
OCPD
Treatment
• Psychotherapy
-Cognitive behavioural therapy (among most of the effective treatment)
-group/interpersonal therapy
-psychodynamic therapy
• Pharmacologycal
-Antidepressants. Antidepressants may be useful if you have a depressed mood, anger, impulsivity, irritability or hopelessness, which
may be associated with personality disorders.
-Mood stabilizers. As their name suggests, mood stabilizers can help even out mood swings or reduce irritability, impulsivity and
aggression.
-Antipsychotic medications. Also called neuroleptics, these may be helpful if your symptoms include losing touch with reality
(psychosis) or in some cases if you have anxiety or anger problems.
-Anti-anxiety medications. These may help if you have anxiety, agitation or insomnia. But in some cases, they can increase impulsive
behavior, so they're avoided in some personality disorders.
• Hospitalization
-When unable to take of himself properly
-tend to harm himself or others
Personality disorder NOS (DSM IV)
Personality disorder-trait specified (DSM V)
This category is for disorders of personality
The essential features of a personality disorder are
functioning that do not meet criteria for any specific impairments in personality (self and interpersonal)
Personality Disorder.
functioning and the presence of pathological
personality traits. To diagnose a personality
• An example is the presence of features of more disorder, the following criteria must be met:
than one specific Personality Disorder that do
not meet the full criteria for any one Personality A. Significant impairments (i.e., mild impairment or
Disorder (“mixed personality”), but that together
greater) in self (identity or self-direction) and
cause clinically significant distress or impairment
interpersonal (empathy or intimacy) functioning.
in one or more important areas of functioning
B. One or more pathological personality trait
(e.g., social or occupational).
domains OR specific trait facets within domains,
considering ALL of the following domains.
• This category can also be used when the clinician
1. Negative Affectivity
judges that a specific Personality Disorder that is
2. Detachment
not included in the Classification is appropriate.
3. Antagonism
4. Disinhibition vs. Compulsivity
• Examples include depressive personality disorder
5. Psychoticism
and passiveaggressive personality disorder (see
Appendix B in DSM-IVTR for suggested research
NOTE: Trait domain or one or more trait facets
criteria).
MUST be rated as “mildly descriptive or greater. If
trait domain is rated as “mildly descriptive” then
one or more of the associated trait facets MUST be
rated as “moderately descriptive” or greater..
C. The impairments in personality functioning and the
individual‟s personality trait expression are relatively
stable across time and consistent across situations
D. The impairments in personality functioning and the
individual‟s personality trait expression are not better
understood as normative for the individual‟s
developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the
individual‟s personality trait expression are not solely
due to the direct physiological effects of a substance
(e.g., a drug of abuse, medication) or a general medical
condition (e.g., severe head trauma)