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Personality Disorders
Personality
Personality – specific character traitstemperament, emotional reactivity, fairness,
interpersonal relations establishment, needs,
expectations, stinginess, generosity, arrogance,
independence and others...typical for concrete
person formed by early adulthood, persist
throughout life.
Personality disorders
Personality disorder- when personality traits are
rigid and self-defeating, they may interfere with
functioning and even lead to psychiatric
symptoms
 cause more or less suffering of patient or other
persons or both and lead to social
maladaptation (relations, family, work...)
 such personality seems to be disbalanced,
whithout harmonical coordination of behaviour
Main Features of PDs
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Extreme patterns of thinking, feeling, and
behaving that deviate from a person’s culture
Listed on Axis II of the DSM-IV-TR
Begin early in life and remain stable
- not contextual or transient
Inflexible and maladaptive
Cause significant functional impairment and
subjective distress
- ego-syntonic vs. ego-dystonic
Historical Aspects
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The concept of PD has been described for
thousand of years. In the 4th century B.C.,
Hippocrates concluded that all disease
stemmed from an excess of or imbalance
among four bodily humors: yellow bile,
black bile, blood and phlegm.
Historical Aspects
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Hippocrates identified four fundamental
personality styles:
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Irritable and hostile, choleric (yellow bile)
Pessimistic, melancholic (black bile)
Overly optimistic and extraverted, sanguine
(blood)
Apathetic, phlegmatic (phlegm)
PD first recognized apart from psychosis
in 1801.
In 19th century psychiatrist embraced the
term “Moral Insanity”
Incidence
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Prevalence of PD in the general
population is 5 to 10 %.
Occurrence of mixed PD is common than
a single PD in an individual
Incidence
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Paranoid 0,5-2,5%
Schizoid ?%
Schizotypal 3%
Antisocial 3% (disocial in ICD-10)
Borderline 2%
Histrionic 2-3%
Narcissistic less than 1%
Avoidant 0,5-1%
Dependent 2,5-25%
DSM-IV-TR Personality Disorders
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Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder
Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive-Compulsive Personality
Disorder
Cluster A
Cluster B
Cluster C
ICD-10 Classification
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F 60-69 Disorders of adult personality
and behavior
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F 60
F60.0
 F60.1
 F60.2
 F60.3
 F60.4
 F60.5
 F60.6
 F60.7
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Specific personality Disorders
Paranoid PD
Schizoid PD
Dissocial PD
Emotionally Unstable PD
Histrionic PD
Anankastic PD
Anxious PD
Dependent PD
ICD-10 Classification
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F61
F62
Mixed and other PD
Enduring personality changes, not
attributable to brain damage and
disease
Note :- the 3rd edition of DSM included
passive-aggressive PD in Cluster C in
DSM-IV this included in the section of
criteria provided for further study
Etiology
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Exact cause is unknown
Genetic factors
Biological factors:- poor regulation of brain
circuits that control emotion
Psychodynamic theories:- deficiencies in
ego and superego development and may
relate to mother-child relationship (over
protectiveness, early separation,
unresponsiveness)
Etiology
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Maternal deprivation, especially in
antisocial personality
Borderline personalities are more likely to
report physical and sexual abuse in
childhood.
Dependent personality may be due to
fixation in the oral stage of development
Etiology
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Paranoid personality is due to absence of
trust, which results from lack of parental
affection in childhood and persistent
rejection by parents leading to low self
esteem.
Histrionic personality is said to occur as a
result of failure to resolve oedipal complex
and excessive use of repression as a
mechanism of defense.
Cluster A: Odd or Eccentric
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Paranoid PD – is a pattern of distrust and
suspiciousness such that others’ motives are
interpreted as malevolent
Schizoid PD – is a pattern of detachment from
social relationships and restricted range of
emotional expression
Schizotypal PD – is a pattern of acute discomfort
in close relationships, cognitive or perceptual
distortions, and eccentricities of behaviour
Paranoid Personality Disorder
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suspicious of other’s motives
interprets actions of others as deliberately
demeaning/threatening
expectation of being exploited
see hidden messages in benign comments
easily insulted/ bears grudges
appear cold and serious
More commonly diagnosed in men than
women.
Schizoid Personality Disorder
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indifferent to relationships
limited social range (some are hermits)
aloof, detached, called loners
no apparent need of friends, sex
solitary activities
seem to be missing the “human part”
Appear indifference to the praise or
criticism
Schizotypal Personality Disorder
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peculiar patterns of thinking and
behaviour
perceptual and cognitive disturbances
magical thinking(superstitiousness,
belief in clairvoyance)
Idea of reference
Odd thinking and speech
Excessive social anxiety
Cluster B: Dramatic, Emotional, or
Erratic
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Antisocial PD – is a pattern of disregard for, and
violation of, the rights of others
Borderline PD – is a pattern of instability in
interpersonal relationships, self-image, and
affects, and marked impulsivity
Histrionic PD – is a pattern of excessive
emotionality and attention seeking
Narcissistic PD – is a pattern of grandiosity,
need for admiration, and lack of empathy
Antisocial Personality Disorder
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pattern of irresponsibility, recklessness, impulsivity
beginning in childhood or adolescence (e.g., lying,
truancy)
Occurring since age 15 yrs.
adulthood:
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criminal behaviour
little adherence to societal norms,
little anxiety
conflicts with others
callous/exploitive
Psychopathy
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Egocentric, deceitful, shallow, impulsive
individuals who use and manipulate others
Callous, lack of empathy
Little remorse
Thrill-seeking
“human predators” (Hare, 1993)
No “conscience”
At least 18 yrs old.
Borderline Personality Disorder
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marked instability of mood, relationships,
self-image
intense, unstable relationships
uncertainty about sexuality
everything is “good” or “bad”
chronic feeling of “emptiness”
recurrent threats of self-harm/ “slashers”
Transient stress related paranoid ideation
Histrionic Personality Disorder
excessive emotional displays/
dramatic behaviour
 attention-seeking, victim stance
 seek re-assurance, praise
 shallow emotions, flamboyant, selfcentred
 very seductive, “life of the party”
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Narcissistic Personality Disorder
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grandiose sense of self-importance
Preoccupied with fantasies of unlimited success
lack of empathy
hyper-sensitive to criticism
exaggerate accomplishments/ abilities
Believe that he/she is special and unique
Has a sense of entitlement
below surface is fragile self-esteem
Lack empathy, shows arrogant behavior
Cluster C: Anxious or Fearful
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Avoidant PD – is a pattern of social inhibition,
feelings of inadequacy, and hypersensitivity to
negative evaluation
Dependent PD – is a pattern of submissive and
clinging behaviour related to an excessive need
to be taken care of
Obsessive-Compulsive PD – is a pattern of
preoccupation with orderliness, perfectionism,
and control at the expense of flexibility
Avoidant Personality Disorder
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over-riding sense of social discomfort
easily hurt by criticism
always need emotional support
occasionally try to socialize
so distressing they retreat into
loneliness
Views self as socially inept, inferior to
others.
Dependent Personality Disorder
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Feel uncomfortable or helpless when alone
Submissive, clingy behaviour
fear of separation
easily hurt by criticism
Has difficulty making everyday decisions
without an excessive amount of advice from
others.
Has difficulty initiating projects or doing
things
Obsessive-Compulsive
Personality Disorder
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Excessive control and perfectionism
Inflexible, rigid, and stubborn
Preoccupied with trivial details, rule, list, order
Judgmental/Moralistic,
Workaholic/Ignore family members
Is excessively devoted to work to the exclusion
of leisure activity & friendship
Is reluctant to delegate tasks
High standards
Passive Aggressive PD
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Negative attitudes and passive resistance
Complains of being misunderstood &
unappreciated by others
Unreasonably criticizes and scorns
authority
Voices exaggerated and persistent
complaints of personal misfortune
Is sullen and argumentative
Personality Disorder Not
Otherwise Specified
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Meets general criteria for a PD but no
specific criteria for a specific PD.
Exhibit at least 10 symptoms of PDs
across all subtypes
Diagnostic process
-Complete psychiatric examination
-Objectivisation- obj.anamnesis, observation
-Exclusion of secondarity -somatic examination,
brain imaging, EEG, laboratory (BCH,
toxicology, infections, endokrinology)
-Psychological examination -personality tests
Complications
-secondary mental illnesses (depression,
medicament, drug or alcohole abuse or
addiction, eating disorders, impulse-control
disorders, anxiety disorders, short psychosis)
-suicidal behavior
-acts of self-harm
-violence and crime behaviour
-risk behaviour (sexualy transmitted infections,
drug application...)
Treatment
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Motivation to the therapy, compliance
and efficiency is different from case to
case.
Psychoterapy – group, occupational,
recreational, behaviour, milieu therapy.
Pharmacotherapy -in some cases,
symptomatic , very limited role or use
with associated disorders
Psychotherapy
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Interpersonal Psychotherapy
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Depending on the therapeutic goal IP may Is brief
and time limited or long term exploratory
Suggested for the clients with paranoid, schizoid,
schizotypal, borderline, dependent, narcissistic,
OCPD.
Psychoanalytical
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Treatment of choice for histrionic PD
Focuses on the unconscious motivation for
seeking total satisfaction from others and for
being unable to commit oneself to a stable,
meaningful relationship.
Psychotherapy
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Milieu or Group Therapy
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Especially for antisocial PD, who respond
more adaptively to support and feedback from
peer
May be helpful in overcoming social anxiety
and developing interpersonal trust in client
with avoidant PD
Helpful in dependent PD
Psychotherapy
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Cognitive and Behaviour Therapy
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May be useful for OCPD, passive-aggressive,
antisocial and avoidant PD.
Social skills training and assertiveness
training alternative ways to deal with
frustration.
Cognitive strategies help the client recognize
and correct inaccurate internal mental
schemata.
Psychotherapy
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Others
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Occupational therapy to increase the level of
functioning so that they become more
independent.
Recreation therapy can assist patients to
ventilate feelings and increase socialization
skills.
Pharmacotherapy for
symptoms
depression- SRI, MAOI, atyp.AP
acute anxiety and agitation- BZD, AP
anxiety- (S)SRI, buspiron, MAOI, low dose AP
em. instability- VAL, CBZ, Li, low dose AP
em. flateness- atyp.AP, SSRI, MAOI
dysforia- SSRI, low dose atyp.AP
aggression- Li, antikonv., AP
impulsivity- SSRI, anticonv., Li, low dose AP
psychotic- AP
Psychopharmacotherapy
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Antipsychotic helpful for psychotic
symptoms experience by client with
Paranoid, Schizotypal, and Borderline PD
SSRI and MAOIs have been successful in
decreasing impulsivity and self destructive
acts in Borderline PD
Lithium carbonate and propanolol may be
helpful for the violent episode in Antisocial
Anxiolytics for Avoidant PD