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PERSONALITY DISORDER May 25, 2017 The DSM – IV – TR (American Psychiatric Association, 2000) defines personality traits as “Enduring patterns of perceiving, relating to, & thinking about the environment & oneself that are exhibited in a wide range of social & personal contexts.” May 25, 2017 Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Personality Disorder Antisocial Personality Disorder Borderline Personality Disorder Histrionic Personality Disorder Narcissistic Personality Disorder Avoidance Personality Disorder Dependent Personality Disorder Obsessive-compulsive Personality Disorder 11. Passive-aggressive Personality Disorder 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. May 25, 2017 May 25, 2017 The DSM-IV-TR defines paranoid personality disorder as “a pervasive distrust & suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood & present in a variety of contexts” (APA, 2000). May 25, 2017 The prevalence of paranoid personality disorders is estimated at 0.5% to2.5% of the general population, it’s more common in males. May 25, 2017 The hallmarks of paranoid personality disorder are suspicion & distrust of others’ motives. Other features include: Refusal to confide in others Inability to collaborate with others Hypersensitivity Inability to relax (hypervigilance) Self-righteousness Detachment & social isolation Poor self – image Sullenness, hostility, coldness & detachment Humorlessness Anger, jealousy & envy Bad temper, hyperactivity & irritability Lack of social support systems. May 25, 2017 The specific cause of paranoid personality disorder is unknown. Its higher incidence in families with a schizophrenic member suggests a possible genetic influence. Some expert believe that the disorder result (at least partly) from negative childhood experiences & a threatening domestic atmosphere – for example, extreme unfounded rage or condescension by the parents, which can produce profound insecurity in the child. May 25, 2017 May 25, 2017 Schizoid personality disorder is characterized primarily by a profound defect in the ability to form personal relationships or to respond to others in any meaningful, emotional way (Phillips, Yen, & Gunderson, 2003). These individual displays a lifelong pattern of social withdrawal & their discomfort with human interaction is very apparent. May 25, 2017 Epidemiological Statistics:- The prevalence of schizoid personality disorder within general population has been estimated at between 3 & 7.5%. it is diagnosed more frequently in men. May 25, 2017 Clinical Features Emotional detachment Inability to experience pleasure Lack of strong emotions & little observable change in mood Avoidance of activities that involve significant interpersonal contact Little desire for or enjoyment of close relationships No desire to be part of a family Strong preference for solitary activities Little or no interest in sexual experiences with another person Lack of close friends or confidants other than immediate family members Shyness, distrust & discomfort with intimacy feeling of superiority loneliness self-consciousness Oversensitivity to slights. May 25, 2017 Predisposing Factors As with the other personality disorders, the exact cause of schizoid personality disorder isn’t known. Some researchers think it may be inherited. Other possible causes may include: A sustained history of isolation during infancy & childhood Cold or grossly deficient early parenting Parental modeling of interpersonal withdrawal, indifference, & detachment. May 25, 2017 SCHIZOTYPAL PERSONALITY DISORDER May 25, 2017 DEFINITION:- SCHIZOTYPAL PERSONALITY DISORDER IS MARKED BY A PERVASIVE PATTERN OF SOCIAL & INTERPERSONAL DEFICITS, ALONG WITH ACUTE DISCOMFORT WITH OTHERS. PEOPLE WITH THIS DISORDER HAVE ODD THOUGHT & BEHAVIOURAL PATTERNS. Epidemiological Statistics:Schizotypal personality disorder is found in about 3% of the general population. it’s slightly more common in men than in women. May 25, 2017 Odd or eccentric behaviour or appearance Inaccurate beliefs that other’s behaviour or environmental phenomena are meant to have an effect on the patient Odd beliefs or magical thinking (such as thinking that one’s thought or desires can influence the environment or cause events to occur) Unusual perceptual experiences, including bodily illusions Vague, circumstantiallty, or stereotypical speech or thinking Unfounded suspicious of being followed, talked about, persecuted, or under surveillance Inappropriate or constricted affect Lack of close relationships other than immediate family members Social isolation Excessive social anxiety A sense of feeling different & not fitting in with others easily May 25, 2017 Predisposing Factors:Schizotypal personality disorder may have a genetic basis. Family, twin & adoption studies show an increased risk of the condition in people with a family history of schizophrenia. Environmental factors (such as severe stress) may determine whether schizotypal personality disorder or schizophrenia manifests. Dopamine Deviance: Some evidence suggests that patients with schizotypal personality disorder have poor regulation of dopamine pathways in the brain. Psychological & Cognitive theories: psychological & cognitive explanations for schizotypal personality disorder focus on deficits in attention & information processing. These patients perform poorly on tests that assess continuous performance tasks, which require the ability to maintain attention on one object & to look at new stimuli selectively. Psychoanalytic theories: One proposes that patients with this disorder have ego boundary problems; the other, that these patients were raised by patients with inadequate parenting skills, poor communication skills & loose association of words. May 25, 2017 ANTISOCIAL PERSONALITY DISORDER May 25, 2017 Definition:The highlight of antisocial personality disorder is chronic antisocial behaviour that violates other’s rights or generally accepted social norms. This disorder predisposes a person toward criminal behaviour. Epidemiological Statistics:In the general population, the prevalence of antisocial personality disorder is about 2% to 3%. Roughly one-half of people with this disorder have a history of arrest. It affects three to four times as many males than females. May 25, 2017 Clinical Features:A patient with antisocial personality disorder has a long-standing pattern of disregarding other’s right & society’s values. Other assessment finding may include: Repeatedly performing unlawful acts Reckless disregard for his own or others’ safety Deceitfulness Lack of remorse Consistent irresponsibility Power-seeking behaviour Destructive tendencies Impulsivity & failure to plan ahead Superficial charm Manipulative nature Inflated, arrogant self-appraisal Irritability & aggressiveness Inability to maintain close personal or sexual relationships Disconnection between feelings & behaviours Substance abuse May 25, 2017 Predisposing Factors:Genetic & biological factors may influence the development of antisocial personality disorder. Biological factors include: Poor serotonin regulation in certain brain regions, which may decrease behavioural inhibition. Reduce autonomic activity & developmental or acquired abnormalities in the prefronatal brain systems. Such biological factors may underlie the low arousal, poor fear conditioning & decision-making deficits seen in patients with antisocial personality disorder. Children at risk Other possible causes or risk factors include attention deficit hyperactivity disorder, large families & childhood exposure to these conditions: Substance abuse Criminal behaviour Physical or sexual abuse Neglectful or unstable parenting Social isolation Transient friendships Low socioeconomic status May 25, 2017 May 25, 2017 A disorder of poor regulation of emotions, borderline personality disorder is marked by a pattern of instability in interpersonal relationships, mood, behaviour & self image. Although people with this disorder may experience it in various ways, most find it hard to distinguish reality from their own misperceptions of the world. Their emotions overwhelm their cognitive functioning, creating many conflicts with others. May 25, 2017 Epidemiological Statistics:The prevalence of borderline personality disorder affects 2% to 3% of the general population, about 11% of psychiatric outpatients, & nearly 20% of psychiatric inpatients. It’s three times more common in females than in males. Clinical Features:Major signs & symptoms of borderline personality disorder fall into four main categories – unstable relationships, unstable self-image, unstable emotions, & impulsivity. Symptoms are more acute when the patient feels isolated & without social support. Assessment findings may include: A pattern of unstable & intense interpersonal relationships Splitting (viewing others as either extremely good or extremely bad) Intense fear of abandonment, as displayed in clinging & distancing maneuvers Rapidly shifting attitudes about friends & loved ones Desperate attempts to maintain relationships May 25, 2017 Unstable perceptions of relationships Manipulation, as in pitting people against one another Limited coping skills Dissociation (separating objects from their emotional significance) Transient, stress-related paranoid ideation or severe dissociative symptoms Inability to develop a healthy sense of oneself Uncertainty about major issues, such as self-image, identity, life goals, sexual orientation, values, career choices or types of friends Imitative behaviour Rapid, dramatic mood swings, from euphoria to intense anxiety to rage, within hours or days Acting out of feelings instead of expressing them appropriately or verbally Inappropriate, intense anger or difficulty controlling anger Chronic feelings of emptiness Unpredictable self-damaging behaviour, such as driving dangerously, gambling, sexual promiscuity, overeating, spending & abusing substances Self-destructive behaviour, such as physical fights, recurrent accidents, selfmutilation & suicidal gestures May 25, 2017 The precise causes of borderline personality disorder are unknown, but several theories are being investigated. Because it’s five time more common in firstdegree relatives of people who have it, researchers suspect genetic may play a role. Biological factors may involve: Dysfunction in the brain’s limbic system or frontal lobe Decreased serotonin activity Increased activity in alpha-2-noradrenergic receptors. Early losses & abuse:Prolonged separation from their parents, other major losses early in life, & physical, sexual, or emotional abuse or neglect seem to be more common in patients with this disorder than in the general population. May 25, 2017 May 25, 2017 Definition:This disorder is characterized by colorful, dramatic, & extroverted behaviour in excitable, emotional people. They have difficulty maintaining long-lasting relationships, although they require constant affirmation of approval & acceptance from others. Epidemiological Statistics:The prevalence of the disorder is thought to be about 2 to 3%, & it is more common in women than in men. May 25, 2017 may reveal: Assessment of a patient with histrionic personality disorder Constant craving for attention, stimulation, & excitement Intense affect Shallow, rapidly shifting expression of emotions Flirting & seductive behaviour Overinvestment in appearance Exaggerated, vague speech Self-dramatization Impulsivity Exhibitionism Suggestibility & impressionability Egocentricity, self-indulgence, & lack of consideration for others Intolerance of frustration, disappointment, & delayed gratification May 25, 2017 Somatic (physical) preoccupations & symptoms Angry outbursts & tantrums Sudden enraged, despairing, or fearful states Intense anger toward people viewed as withholding Divisive, manipulative behaviour Intolerance of being alone Suppression or denial of internal distress, weakness, depression or hostility Dread of growing old Demanding & manipulative nature Use of alcohol or drugs to quickly alter negative feelings Depression Suicidal gestures & threats. May 25, 2017 The cause of histrionic personality disorder isn’t known. A genetic component may be involved, as hysterical traits are more common in relatives of those with this disorder. However, little research has been done on the biological origins of this disorder. Childhood events may come into play as well. Psychoanalytic theories focus on seductive & authoritarian attitudes by fathers of these patients. May 25, 2017 May 25, 2017 Definition:Persons with narcissistic personality disorder have an exaggerated sense of self-worth. They lack empathy, & are hypersensitive to the evaluation of others. They believe that they have the inalienable right to receive special consideration & that their desire is justification for possessing whatever they seek. Epidemiological Statistics:Narcissistic personality disorder is found in less than 1% of the general population. It affects about three times as many males as females. May 25, 2017 In a patient with narcissistic personality disorder, assessment finding may include: Arrogance or naughtiness Self-centeredness Unreasonable expectations of favorable treatment Grandiose sense of self-importance Exaggeration of achievements & talents Preoccupation with fantasies of success, power, beauty, brilliance or ideal love Manipulative behaviour Constant desire for attention & admiration Lack of empathy Lack of concern over whom he offends Taking advantage of others to achieve his own goals Rage, shame or humiliation in response to criticism May 25, 2017 The exact cause of narcissistic personality disorder is unknown. A psychodynamic theory purposes that it arises when a child’s basic needs go unmet. Love thyself, hate thyself: Another theory holds that patients with this disorder have an ambivalent self-perception: an idealized (or overidealized) view of the self coexists with deep feelings of inferiority & low self-esteem. Thus, the grandiose image is an effort to cover feelings of inferiority. According to this theory, the patient received little encouragement & support from his parents during childhood & tends to internalize the process by looking for these feelings within him-self. May 25, 2017 May 25, 2017 Definition:Avoidant personality disorder is marked by feelings of inadequacy, extreme social anxiety, social withdrawal, & hypersensitivity to other’s opinions. People with this disorder have low self-esteem & poor self-confidence. They dwell on the negative & have difficulty viewing situations & interactions objectively. Epidemiological Statistics:The prevalence of the disorder in the general population is between 0.5 & 1%, & it appears to be equally common in men & women. May 25, 2017 A patient with avoidant personality disorder may exhibit or report: Shyness, timidity, & social withdrawal Behaviour or appearance that’s meant to drive others away (which gives him a sense of control) overtalkativeness Constant mistrust or wariness of others Testing of others’ sincerity Difficulty starting & maintaining relationships Perfectionism Rejection of people who don’t live up his impossibly high standards Limited emotional expression Tenseness & anxiety Low self-esteem Feelings of being unworthy of successful relationships Self-consciousness Loneliness Reluctance to take personal risks or engage in new activities Frequent escapes into fantasy, such as by excessive reading, watching TV, or daydreaming. May 25, 2017 Avoidant personality disorder most likely results from a combination of genetic, biological, environmental, & other factors – although the evidence for genetic & biological causes is weak. From a psychodynamic view, the disorder has been attributed to an overly critical parental style Avoidant personality disorder is closely linked to temperament. Studies of children under age 2 found that some have an apparently inborn tendency to withdraw from new situation or people. In fact, roughly 10% of toddlers are habitually fearful & withdrawn when exposed to new people & situation. Some evidence suggests that a timid temperament in infancy may predispose a person to developing avoidant personality disorder later in life. May 25, 2017 - Information overload: The inherited tendency to be shy may result from overstimulation or an excess of incoming information. The patient cant’s cope with the excess information & withdraws in defense. Inability to cope with the information overload may stem from a low autonomic arousal threshold. - Low threshold, grater response: Research suggests that in people with this disorder, certain structures in the brain’s limbic system may have a lower threshold of arousal & a more pronounced response when activated. Some expert believe that significant environmental influences during childhood, such as rejections or peers, leads to the full development of avoidant personality disorder. May 25, 2017 May 25, 2017 Dependent personality disorder is characterized by “a pervasive & excessive need to be taken care of that leads to submissive & clinging behaviour & fear of separation”. Epidemiological Statistics:In the general population, its prevalence is about 1.5%. it affects slightly more females than males. May 25, 2017 Assessment findings in a patient with dependent personality disorder may include: Submissiveness Self-effacing, apologetic manner Low self-esteem Lack of self-confidence Lack of initiative Incompetence & a need for constant assistance Intense, unremitting need to be loved in a stable longterm relationship that goes through minimal change Anxiety & insecurity, especially when deprived of a significant relationship Feelings of inferiority, & unworthiness Hypersensitivity to criticism May 25, 2017 In females, little need to overtly control or complete with others Demanding behaviour Use of cajolery, bribery, promises to change, & even threats to maintain key relationships Fear & anxiety over losing a relationship or being alone Dependence on a number of people, any one of whom could substitute for the other Difficulty making everyday decisions without advice & reassurance Avoidance of change & new situations Exaggerated fear of losing support & approval. May 25, 2017 The exact cause of dependent personality disorder isn’t known. - Because it tends to run in families, it may involve a genetic component. According to some expert, authoritarian or overprotective parenting may lead to high levels of dependency. These parenting styles may cause the child to believe that she can’t function without other’s guidance & protection & that the way to maintain relationships is to give in to others’ demand Possible contributing factors may include: Childhood trauma Closed family system that discourages outside relationships Childhood physical or sexual abuse Social isolation May 25, 2017 OBSESSIVE – COMPUSIVE PERSONALITY DISORDER May 25, 2017 Individual with obsessive –compulsive personality disorder are very serious & formal & have difficulty expressing emotions. They are overly disciplined, perfectionistic, & preoccupied with rules. They are inflexible about the way in which things must be done & have a devotion to productivity to the exclusion of personal pleasure. The prevalence of the disorder in the general population is 1.5%, - about twice as many males as females. May 25, 2017 A patient with obsessive-compulsive personality disorder may describe his symptoms in a logical way, attaching little emotion to any physical discomfort. Assessment findings commonly include: Behavioural, emotional, & cognitive rigidity Perfectionism Severe self-criticism Indecisiveness Controlling manner Difficulty expressing tender feelings Poor sense of humor Cool, distant, formal manner Emotional constriction Excessive discipline Aggression, competitiveness, & impatience Bouts of intense anger when things stray from the patient’s idea of how things “should be” May 25, 2017 Difficulty incorporating new information into his life Psychosomatic complaints Hypochondriasis Sexual dysfunction Chronic sense of time pressure & inability to relax Indirect expression of anger despite an apparent undercurrent of hostility hoarding of memory & other possessions Preoccupation with orderliness, neatness & cleanliness Discuss about morality, ethics or values Signs & symptoms of depression Physical complaints (commonly stemming from overwork). May 25, 2017 Genetic & developmental factors may play a role in the development of this disorder. A twin & adoption study suggests that it runs in families. Psychodynamic theories view the patient as needing control as a defense against feelings of powerlessness or shame. May 25, 2017 May 25, 2017 Definition:- The DSM-IV-TR defines this disorder as a pervasive pattern of negativistic attitudes & passive resistance to demands for adequate performance in social & occupational situations that begins by early adulthood & occurs in a variety of contexts. May 25, 2017 Features:- Feels cheated & unappreciated Passively resists fulfilling routine social & occupational tasks Complains of being misunderstood & unappreciated by others Argumentative Unreasonably criticizes & scorns authority Expresses envy & resentment toward those apparently more fortunate Voices exaggerated & persistent complaints of personal misfortune. Alternates between hostile defiance & contrition May 25, 2017 Contradictory parental attitude & behaviour are implicated in the predisposing to passive-aggressive personality disorder. Through this type of environment, children learn to control their anger for fear of provoking parental withdrawal & not receiving love & support – even on an inconsistent basis. Overtly the child appears polite & undemanding; hostility & inefficiency are manifested only covertly & indirectly. May 25, 2017 Most clinicians believe it best to strive for lessening the inflexibility of the maladaptive traits & reducing their interference with everyday functioning & meaningful relationship. Selection of intervention is generally based on the area of greatest dysfunction, such as cognitive, affect, behaviour or interpersonal relations. May 25, 2017 Interpersonal psychotherapy may be particularly appropriate because personality disorders largely reflect problems in interpersonal style. Long-term psychotherapy attempts to understand & modify the maladjusted behaviours, cognition, & affects of clients with personality disorders that dominate their personal lives & relationships. The core element of treatment is the establishment of an empathic therapist-client relationship, based on collaboration & guided discovery in which the therapist functions as a role model for the client. Interpersonal psychotherapy is suggested for clients with paranoid, schizoid, schizotypal, borderline, dependent, narcissistic, & obsessive-compulsive personality disorders May 25, 2017 The treatment of choice for individuals with histrionic personality disorder has been psychoanalytical psychotherapy. Treatment focuses on the unconscious motivation for seeking total satisfaction from others & for being unable to commit oneself to a stable, meaningful relationship. May 25, 2017 This treatment is especially appropriate for individuals with antisocial personality disorder, who respond more adaptively to support & feedback from peers. In milieu or group therapy, feedback from peers is more effective than in one-to-one interaction with a therapist. Group therapy – particularly homogeneous supportive groups that emphasize the development of social skills – may be helpful in overcoming social anxiety & developing interpersonal trust & rapport in clients with avoidant personality disorder. May 25, 2017 Behavioural strategies offer reinforcement for positive change. Social skills training & assertiveness training teach alternative ways to deal with frustration. Cognitive strategies help the client recognize & correct inaccurate internal mental schemata. This type of therapy may be useful for clients with obsessive-compulsive, passive-aggressive, antisocial, & avoidant personality disorders. May 25, 2017 Drugs have no effect in the treatment of the disorder itself, some symptomatic relief can be achieved Antipsychotic medications are helpful in the treatment of psychotic decompensation experienced by clients with paranoid, schizotypal, & borderline personality disorder. Antipsychotic have resulted in improvement in illusions, ideas of reference, paranoid thinking, anxiety & hostility in some clients. The selective serotonin reuptake inhibitors (SSRIs) & monoamine oxidase inhibitors (MAOIs) have been successful in decreasing impulsivity & self-destructive acts in the clients with borderline personality disorder. Lithium carbonate & propranolol (Inderal) may be useful for the violent episodes observed in the clients with antisocial personality disorder. Anxiolytics are useful for clients with avoidant personality disorder May 25, 2017 May 25, 2017 1. R/t rage reactions, negative rolemodeling, and inability to tolerate frustration. Convey an accepting attitude towards this client. Work on development of trust, keep all promises & convey the message that it is not him or her but the behaviour that is unacceptable. Maintain low level of stimuli in client’s environment (low lighting, few people, simple décor, low noise level). Observe client’s behaviour frequently during routine activities & interactions, avoid appearing watchful & suspicious. Remove all dangerous objects from client’s environment. May 25, 2017 Help client identify the true object of his or her hostility. Encourage client to verbalize hostile feelings gradually. Explore with client alternative ways of handling frustration. Staff should maintain & convey a calm attitude. Administer tranquilizing medications as ordered by physician or obtain an order if necessary. Monitor for effectiveness & for adverse side effects. If client is not calmed by “talking down” or by medication, use of mechanical restraints may be necessary. May 25, 2017 R/t dysfunctional family system, evidenced by disregards for societal norms & laws, absence of guilty feelings, or inability to delay gratification. From the onset, client should be made aware of which behaviour are acceptable & which are not. Explain consequences of violation of the limits. Do not attempt to coax or convince client to do the “right thing.” Do not use the words “you should (or shouldn’t)….”, Provide positive feedback or reward for acceptable behaviours. May 25, 2017 Being to increase the length of time requirement for acceptable behaviour in order to achieve the reward. A milieu unit provides the appropriate environment for the client with antisocial personality. Help client to gain insight into his or her own behaviours. Talk about past behaviours with client. Discuss behaviours that are acceptable by society & those which are not. Throughout relationship with client, maintain attitude of “It is not you, but your behaviour, that is unacceptable.” May 25, 2017 3. Chronic low self-esteem R/t repeated negative feedback resulting in diminished self-worth, evidenced by manipulation of others to fulfill own desires or inability to form close, personal relationships. 4. Impaired social interaction R/t to negative role modeling & low self-esteem, evidenced by inability to develop a satisfactory, enduring, intimate relationship with another. 5. Deficient knowledge (self-care activities to achieve & maintain optimal wellness) R/t lack of interest in learning & denial of need for information, evidenced by demonstration of inability to take responsibility for meeting basic health practices. May 25, 2017 THANK YOU May 25, 2017