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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.