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PERSONALITY DISORDER
In ICD-10, personality disorders are described as severe disturbance of
personality and behavior that are pronounced deviations, from normal
cultural patterns.
According to DSM-IV, the crucial criterion for distinguishing deviant
personality traits is the presence (evidence) of long-term maladaptation
and inflexibility, manifested as subjective distress, or socio professional
functional impairment, or both. DSM-IV defines personality disorders as:
an enduring pattern of inner experience and behavior that deviates
markedly from the expectations of the individual's culture. The pattern is
manifested in two (or more) of the following areas:
1.cognition (i.e., ways of perceiving and interpreting self, other people,
and events)
2.affectivity (i.e., the range, intensity, and appropriateness of emotional
response)
3.interpersonal functioning
4.impulse control
The pattern is stable and of long duration and its onset can be traced back
at least to adolescence or early adulthood. It is inflexible and pervasive
across a broad range of personal and social situations and leads to
clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
DSM-IV arranges categorical personality disorders into three clusters,
each sharing some clinical features:
*Cluster A includes three disorders with odd, aloof, and eccentric
features (paranoid, schizoid, and schizotypal).
*Cluster B includes four disorders with dramatic, impulsive, and erratic
features (borderline, antisocial, narcissistic, and histrionic).
*Cluster C includes three disorders sharing anxious and fearful features
(avoidant, dependent, and obsessive-compulsive).
Cluster A Personality Disorders
Paranoid Personality Disorder: The hallmarks of paranoid personality
disorder 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). Frequently
impairment is mild, but the disorder typically includes occupational and
social difficulties. These patients are at increased risk for major
depressive disorder, obsessive-compulsive disorder, agoraphobia, and
substance abuse or dependence. Paranoid personality disorder has been
postulated to be a prepsychotic antecedent of delusional disorder,
paranoid type. Paranoid personality disorder is distinguished from
schizophrenia (especially paranoid type), delusional disorder, paranoid
type, and mood disorder with psychotic features on the basis of periods
with positive psychotic symptoms such as delusions and hallucinations in
the latter.
Schizoid Personality Disorder: The hallmarks of schizoid personality
disorder are a pervasive pattern of social detachment and a restricted
range of expressed emotions in interpersonal settings. Frequently these
individuals exhibit severe problems in social relations and occupational
problems when interpersonal involvement is required. Social isolation
sometimes favorably affects overall performance. This personality
disorder sometimes appears as the prepsychotic antecedent of delusional
disorder, schizophrenia, or (rarely) major depressive disorder. Schizoid
personality disorder is distinguished from schizophrenia, delusional
disorder, and mood disorder with psychotic features on the basis of
periods with positive psychotic symptoms, such as delusions and
hallucinations, in the latter.
Schizotypal Personality Disorder: The hallmarks of schizotypal
personality disorder are pervasive discomfort with and reduced capacity
for close relationships, as well as cognitive and perceptual distortions and
eccentric behavior (not severe enough to meet criteria for schizophrenia)
magical thinking, oddities in speech, appearance, and thought processes).
Patients with this disorder typically experience occupational and social
difficulties. Transient psychotic episodes can complicate this disorder,
particularly in response to stress. Symptoms sometimes become so
significant that subjects may meet criteria for schizophreniform disorder,
delusional disorder, or brief psychotic disorder. 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.
Cluster B Personality Disorders
Antisocial Personality Disorder: is characterized by pervasive disregard
for, and violation of, rights of others since the age of 15. A person must
be at least 18 years old and have displayed evidence of conduct disorder
before the age of 15. Antisocial personality disorder may be complicated
by dysphoria, tension, low tolerance for boredom, depressed mood, and
premature violent death. Impairment is extremely variable, but typically
includes social difficulties.
DSM-IV Diagnostic Criteria for Antisocial Personality Disorder
A. There is a pervasive pattern of disregard for and violation of the rights
of others occurring since age 15 years, as indicated by three (or more) of
the following:
(1) failure to conform to social norms with respect to lawful behaviors as
indicated by repeatedly performing acts that are grounds for arrest
(2) deceitfulness, as indicated by repeated lying, use of aliases, or
conning others for personal profit or pleasure
(3) impulsivity or failure to plan ahead
(4) irritability and aggressiveness, as indicated by repeated physical fights
or assaults
(5) reckless disregard for safety of self or others
(6) consistent irresponsibility, as indicated by repeated failure to sustain
consistent work behavior or honor financial obligations
(7) lack of remorse, as indicated by being indifferent to or rationalizing
having hurt, mistreated, or stolen from another
B. The individual is at least age 18 years.
C. There is evidence of conduct disorder with onset before age 15 years.
D. The occurrence of antisocial behavior is not exclusively during the
course of schizophrenia or a manic episode.
Narcissistic Personality Disorder: The hallmarks of narcissistic
personality disorder are a pervasive sense of grandiosity (in fantasy or in
behavior), need for admiration, lack of empathy, and chronic intense
envy. These patients are at increased risk for major depression and
substance abuse or dependence (especially cocaine use). Dysthymic
disorder or major depressive disorder may develop in reaction to criticism
or failure.
Histrionic Personality Disorder :The hallmarks of histrionic personality
disorder are pervasive and excessive self-dramatization, excessive
emotionality, and attention seeking. The patients may exhibit frequent
suicidal gestures. Interpersonal relations are unstable, shallow, and
generally ungratifying. Frequent marital problems result from the
tendency to neglect long-term relationships for the excitement of new
relationships. These patients are at increased risk for major depression,
somatization disorder, and conversion disorder.
DSM-IV Diagnostic Criteria for Histrionic Personality Disorder
A pervasive pattern of excessive emotionality and attention seeking,
beginning by early adulthood and present in a variety of contexts, as
indicated by five (or more) of the following:
(1) is uncomfortable in situations in which he or she is not the center of
attention
(2) interaction with others is often characterized by inappropriate sexually
seductive or provocative behavior
(3) displays rapidly shifting and shallow expression of emotions
(4) consistently uses physical appearance to draw attention to self
(5) has a style of speech that is excessively impressionistic and lacking in
detail
(6) shows self-dramatization, theatricality, and exaggerated expression of
emotion
(7) is suggestible, i.e., easily influenced by others or circumstances
(8) considers relationships to be more intimate than they actually are.
Borderline Personality Disorder The hallmarks of borderline personality
disorder are pervasive and excessive instability of affects, self-image, and
interpersonal relationships as well as marked impulsivity.
The disorder may be complicated by psychotic-like symptoms
(hallucinations, body image distortions, hypnagogic phenomena, ideas of
reference) in response to stress and premature death or physical handicap
from suicide and suicidal gestures, failed suicide, and self-injurious
behavior. Frequent and severe impairment may involve frequent job
losses, interrupted education, and broken marriages.
These patients are at increased risk for major depression, substance abuse
or dependence, eating disorder (notably bulimia), posttraumatic stress
disorder, and attention-deficit/hyperactivity disorder.
Cluster C Personality Disorders
Avoidant Personality Disorder Clinical Criteria Avoidant personality
disorder is characterized by pervasive and excessive hypersensitivity to
negative evaluation, social inhibition, and feelings of inadequacy.
Impairment can be severe and typically includes occupational and social
difficulties. These patients are at increased risk for mood and anxiety
disorders (especially social phobia, generalized type).
DEPENDENT PERSONALITY DISORDER The hallmark of dependent
personality disorder is a pervasive, excessive need to be taken care of,
leading to clinging behavior, submissiveness, fear of separation, and
interpersonal dependency . Complications include low socioeconomic
status and poor family and marital functioning.
has difficulty making everyday decisions without an excessive amount of
advice and reassurance from others
, needs others to assume responsibility for most major areas of his or her
life, has difficulty expressing disagreement with others because of fear of
loss of support or approval.
Obsessive-Compulsive Personality Disorder The hallmark of obsessivecompulsive personality disorder is pervasive preoccupation with
orderliness, perfectionism, and mental and interpersonal control, at the
expense of flexibility, openness, and efficiency. Complications include
distress and difficulties when confronted with new situations that require
flexibility and compromise and myocardial infarction (secondary to
features typical of type A personalities, such as time urgency, hostility,
competitiveness). Frequently severe, impairment typically includes
occupational and social difficulties. These patients are at increased risk
for major depression, anxiety disorder, and obsessive-compulsive
disorder. Obsessive-compulsive personality disorder is distinguished from
obsessive-compulsive disorder on the basis of true obsessions and
compulsions in the latter.