Personality disorders

1. Personality Disorders

2. • Personality refers to those enduring qualities
of an individual that are shown in their ways
of behaving in a wide variety of circumstances,
and which we use to distinguish between
people .

3. • Personality disorders behaviors are present
throughout life
• Mental disorders behaviours differ from the
person’s previous behaviour.
• Occurs in 10-20% of general population

4. • Symptoms :
- ego syntonic (acceptable to ego)
- alloplastic (adapt by trying to alter the external
environment rather than themselves).

5. Importance of Personality
• Predisposing factor for other psychiatric
disorders (substance use, suicide, impulse-
control disorder and anxiety disorders)
• Colours the presentation of a psychiatric
disorder
• Affects approach to treatment.

6. Personality types
• Different personality factors are derived from
various traits like:
- Anxiety
- Energy
- Flexibility
- Hostility
- Impulsiveness
- Moodiness
- Orderliness
- Self reliance

7. • Investigators have derived different
personality factors from such traits
• Eysenck proposed 3 dimensions:
- extroversion- introversion
- Neuroticism
- Psychoticism

8. • Cattell identified 5 factors
- Openness to experience (novelty seeking)
- Consciousness
- Extroversion- introversion
- Agreeableness
- neuroticism

9. • Cloninger :
- 3 basic behavioral dispositions expressed as 4
basic temperaments (a 7 factor model):
4 basic temperaments:
- Novelty seeking
- Harm reduction
- Reward dependence
- persistence

10. 3 character traits:
- Self directedness
- Cooperativeness
- transcendence

11. Etiology/ origin of personality
• Genetic factors –
twin studies-
the concordance rate among MZ are higher
than DZ twins .
linkage studies-
linkage between harm avoidance and a region
on 8p21 has reported in one study

12. studies of body shape and personality –
- 3 types of body built are described –
1. Pyknic (stocky and rounded) –
- linked to cyclothymic personality type
(sociable and variable mood)

13. 2. Athletic (muscular)
3. Asthenic (lean and narrow) –
- related to schizotypal personality type (cold,
aloof and self-sufficient)

14. Biological factors
• Hormones –
- high levels of testosterone, 17-estradiol and
estrone in persons who exhibit impulsive
traits.
• Platelet Monoamine oxidase –
- low levels with schizotypal personality

15. • Smooth Pursuit Eye Movements –
- saccadic in persons who are introverted, low
self-esteem
- seen in schizotypal personality disorder .

16. • Neurotransmitters –
- roles of endorphins, serotonin and dopamine
has been studied
- low levels of 5- hydroxyindoleacetic (5-HIAA)
in persons who attempt suicide and in
impulsive and aggressive patients .

17. • Electrophysiology –
- slow wave activity in antisocial and borderline
personality disorders

18. Psychoanalytic factors –
• Sigmund Freud – personality traits are related
to a fixation at psychosexual stage for eg –
- oral : passive and dependent
- anal : stubborn, parsimonious and highly
conscientious .

19. • Wilhelm Reich :
- coined the term ‘character armor’
- defensive styles for protecting themselves
from internal impulses.

20. Defense Mechanisms
• To help those with personality disorders,
psychiatrists must appreciate patients
underlying defenses
• Abandoning a defense increases conscious
awareness of anxiety and depression- a major
reason patients are reluctant to alter their
behavior.

21. 1. FANTASY:
- seen in Schizoid PD
- Person creates imaginary lives, especially
imaginary friends.
2. DISSOCIATION and DENIAL :
- replacement of unpleasant affects with pleasant
ones.
- histrionic personalities

22. 3. ISOLATION:
- Seen in obsessive-compulsive personalities.
- intensified self-restraint, overly formal social
behavior, and obstinacy.

23. 4. PROJECTION:
- patients attribute their own unacknowledged
feelings to others
5. SPLITTING:
- Persons toward whom patients' feelings are,
or have been, ambivalent are divided into
either completely good or bad

24. 6. PASSIVE AGGRESSION:
- Persons turn their anger against themselves.
- phenomenon is called masochism
- includes failure, procrastination, silly or
provocative behavior and frankly self-
destructive acts

25. 7. ACTING OUT:
- patients directly express unconscious wishes
or conflicts through action to avoid being
conscious of accompanying idea or affect.
- Tantrums, motiveless assaults, child abuse,
are common examples

26. 8. PROJECTIVE IDENTIFICATION:
- Seen in borderline personality disorder
- consists of three steps.
1. aspect of self is projected onto someone else.
2. projector then tries to coerce the other person
into identifying with what has been projected.
3. the recipient of the projection and the projector
feel a sense of oneness or union

27. Childhood temperament and adult
personality
• Infants differ in patterns of sleeping and
waking, intensity of emotional responses,
span of attention
• These differences could form the basis for
personality development

28. Assessment of personality
• Difficult :
- Patient’s personality can only be judged by
past behavior from various informants
- Personality tests are used to assess
personality but are difficult to apply in clinical
practice

29. • It is best to record a series of a series of
descriptive terms chosen from the features of
accepted personality disorders which is
fundamental element of good clinical practice
like:
- Sensitive
- Prone to worry
- Lacking in confidence

30. Instruments for diagnosing personality
disorders
1. International personality disorders
examination :
- Assesses PD categorically and dimensionally
- Semi structured clinical interview in 2
versions; a DSM IV version with 99 and ICD 10
version with 67 sets of questions

31. 2. Structured clinical interview for DSM- IV axis II
PD:
- Semi structured clinical interview with 119
sets of questions

32. Personality change
• Lasting personality change in adult life may be
due to :
- Injury to or organic disease of brain
- Severe mental disorder
- Exceptionally severe stressful events

33. ICD- 10
• Disorders of adult personality and behaviour:
Specific personality disorders:
Paranoid personality disorder
Schizoid personality disorder
Dissocial personality disorder
Emotionally unstable personality disorder
- Impulsive type
- Borderline type

34. Histrionic personality disorder
Anankastic personality disorder
Anxious [avoidant] personality disorder
Dependent personality disorder
Other specific personality disorders
Personality disorder, unspecified

35. Specific personality disorder (ICD 10)
Diagnostic guidelines :
Conditions not directly attributable to gross brain
damage or disease, or to another psychiatric
disorder, meeting the following criteria:
(a) markedly disharmonious behaviour, involving
usually several areas of functioning
(b) the abnormal behaviour pattern is enduring, not
just limited to episodes of mental illness

36. (c) pervasive and clearly maladaptive to a broad
range of personal and social situations
(d) appear during childhood or adolescence and
continue into adulthood

37. (e) leads to considerable personal distress but
this may only become apparent late in its
course
(f) usually, but not invariably, associated with
significant problems in occupational and social
performance.

38. Subtypes
• Classified in DSM-5
• Cluster A – paranoid, schizoid, and schizotypal
(odd, aloof features .)
• Cluster B – antisocial, borderline, histrionic
and narcissistic (dramatic, impulsive and
erratic features .)
• Cluster C – avoidant, dependent and obsessive
- compulsive (anxious and fearful features )

39. Paranoid Personality Disorder
• Epidemiology –
• Prevalence – 2-4% in general population
• Relatives of patients with schizophrenia show
higher incidence
• More in minority groups, immigrants and deaf
people.

40. Clinical features
• Hallmark – suspiciousness and distrust
• Pervasive tendency to interpret actions of
others as deliberately demanding or
threatening
• Frequent dispute, without any justification

41. • Bear grudges
• Pathological jealous, question the fidelity of
spouse
• Ideas of reference and logically defended illusions
are common
• Affectively restricted and unemotional

42. • Pride themselves on being rational and
objective
• Pay close attention to power and rank
• Use defense of projection

43. • They can be argumentative, often reading
demeaning or threatening meaning into
innocent remarks
• Take offence easily and se rebuff where none
was intended
• Have sense of self importance and consider
others have prevented them from fulfilling
their potential

44. Differential Diagnosis
• Delusional disorder
• Borderline personality disorder
• Antisocial personality disorder

45. Course and prognosis
• No long term studies
• In some patients it is lifelong
• Others developed in to schizophrenia
• Problems with working and living with others
• Occupational and marital problems are common

46. Treatment
• Psychotherapy –
- Treatment of choice
- Therapist should be straightforward and tried
to maintain trust and tolerance
- individual psychotherapy requires a
professional and not overly warm style of
therapists.

47. • These patients do not perform well in group
therapy
• Delusional accusations must be deal with
realistic and gentle way without humiliating
patient .

48. • Pharmacotherapy – Useful in dealing agitation
and anxiety
• Benzodiazepines
• Antipsychotics

50. Schizoid Personality Disorder
• Epidemiology –
• Affects 5% of general population
• M:F – 2:1

51. Diagnosis & Clinical features
• Emotionally cold, detached and aloof
• Quiet, distant, unsociable.
• Introspective
• Unable to express.
• indifference to either praise or criticism
• insensitivity to social norms and conventions.

52. • Little interest in sexual relationship
• Do not form intimate relationship
• Often remained unmarried

53. Differential diagnosis
• Schizophrenia
• Avoidant personality disorder
• autistic disorder and Asperger's syndrome

54. Course and prognosis
• Onset in early childhood or adolescence
• May be life long .

55. Treatment
• Psychotherapy –
• Schizoid patients are introspective and are
consistent with therapy
• As trust develops, reveals fantasies, imaginary
friends, and fears .
• In group therapy , patient may be silent for
long periods but involved .

56. • Pharmacotherapy –
• Small doses of antipsychotics, antidepressants
and psychostimulants
• SSRIs make patient less sensitive to rejection
• Benzodiazepines may help diminish
interpersonal anxiety

58. Schizotypal Personality Disorder
• Not classified as a personality disorder in ICD-
10 , but placed with schizophrenia and called
schizotypal disorder .

59. Epidemiology
• Occurs in about 3% of population
• Sex ratio is unknown , frequently diagnosed in
females with fragile X syndrome
- DSM-5 suggests it is slightly more common in
males

60. • More association among biological relatives of
schizophrenia
• Higher incidence among MZ twins than DZ

61. Diagnosis & Clinical features
• Experience social anxiety –
- have difficulties in forming relationship
- lack friends
- Feel different from other people

62. • Cognitive and perceptual distortions include –
- ideas of reference (no delusions),
- suspicious ideas
- odd beliefs and
- magical thinking (belief in clairvoyance, mind
reading, telepathy)
- unusual perceptual experiences (awareness of a
‘presence’ , or experiences bordering on
hallucinations)

63. • Oddities of speech –
- unusual constructions, words and phrasing,
vagueness and tendency to digression .
• Affective responses are unusual –
- appear stiff, odd and constricted in their
emotions .

64. • Behavior is eccentric, with odd mannerism,
- unusual choices of clothing,
- disregard of conventions and
- awkward social behavior .

65. Differential diagnosis
• Schizoid and avoidant personality disorders
• Schizophrenia

66. Course and Prognosis
• Considered as a premorbid personality of
patient with schizophrenia .
• Some persons maintains a stable schizotypal
personality .
• 10% patients eventually commit suicide .

67. Treatment
• Psychotherapy –
- Same as for schizoid personality disorder
- Approach should be more sensitive as they
have peculiar pattern of thinking and may
involve in strange religious practices
- Therapist must not ridicule such activities or
be judgemental about these beliefs or
activities .

68. • Pharmacotherapy –
• Antipsychotics are useful in dealing with ideas
of reference and illusions
• Antidepressants when depressive component
of personality is present .

70. Antisocial (Dissocial) Personality
Disorder
• Term ‘Dissocial’ is used in ICD-10

71. Epidemiology
• 1 year prevalence rates are between 0.2 and
3%
• More common in poor urban areas
• Highest prevalence is seen with alcohol use
disorder (over 70%) and in prison population
(over 75%)

72. • More common in males
• 5 times more common among first degree
relatives of men with the disorder .

73. Diagnosis and clinical features
• Patient can appear composed and credible,
but beneath is tension, hostility, irritability
and rage (described by Hervey Cleckley’s in
the mask of sanity) .
• Central feature is lack of concern for others .

74. • Exploitative , Violent and extremely
manipulative
• Sexual activity lacks tenderness
• Inflict cruel or degrading acts on others
• Partners may be physically or sexually abused

75. • Superficial charm, but their relationships are
shallow and short-lived
• Irresponsible and depart from social norms ,
do not obey rules and repeatedly break laws
• Impulsive, rarely plans ahead and have an
unstable work record

76. • Lack of guilt or remorse and failure to change
their behavior in response to punishment or
other adverse outcome
• Avoid responsibility, transferring blames on
other people and rationalizing their own
failures .

77. Differential diagnosis
• Criminal behavior
• Substance abuse disorder

78. Course and prognosis
• Unremitting course , peak of antisocial
behaviour in late adolescence
• Symptoms decrease as person grows older
• Depressive disorder, alcohol use disorder and
other substance abuse are common .

79. Treatment
• Psychotherapy –
- When hospitalized, become amenable to
psychotherapy
- Self-help groups are more useful
- Before treatment begins, firm limits are
essential , to deal with patients’ self
destructive behaviour .

80. • Pharmacotherapy –
- To deal with anxiety, rage and depression
- If evidence of ADHD – psychostimulants such
as methylphenidate is useful
- Controlling impulsive behaviour – antiepileptic
drugs as Carbamazepine , valproate
- β-blockers to reduce aggression .

82. Borderline Personality Disorder
• Patients stand on the border between
neurosis and psychosis, characterized by
extraordinarily unstable affect, mood,
behaviour, object relations and self-image .

83. • The disorder has also been called as –
- ambulatory schizophrenia (Helene Deutsch),
- pseudoneurotic schizophrenia (Paul Hoch and
Phillip Politan), and
- psychotic character disorder (John Frosch).

84. • Otto Kernberg described it as involving –
1. Ego weakness with poor impulse control
2. ‘primary process’ ie. irrational thinking
despite intact reality testing
3. Use of less mature defence mechanisms,
such as projection and denial
4. Diffuse personal identity

85. Epidemiology
• Present in about 1-2% of population
• M:F = 1:2
• Increase prevalence of MDD, alcohol use
disorder and substance abuse is found in first
degree relatives .

86. Diagnosis and clinical features
• ICD-10 uses the term emotionally unstable
personality disorder , which is divided in to –
- borderline type and
- impulsive type (5 criteria for each subtype and
4 are required for diagnosis ).

87. • Borderline type –
1. Disturbed or uncertain self-image
2. Intense and unstable relationship
3. Efforts to avoid abandonment
4. Recurrent threats or acts of self harm
5. Chronic feeling of emptiness

88. • Impulsive type –
- Impulsive
- Liability to anger and violence
- Unstable capricious mood
- Quarrelsome
- Difficulty maintaining a course of action

89. Clinical features
• Life is dominated by strong and fluctuating
emotions
• Strive for affection and intimacy but regularly
disappointed
• Accept strangers as friends or behave
promiscuously
• Exhaust their partners with the intensity of
their emotional demands
• Confused by unpredictability of mood

90. • Insecure in their personal identity and need
reassurance and stability
• Self-harm is common (suicidal attempts or
cutting to release tension)
• Alcohol and drug abuse
• Short lived psychotic episodes (micro-
psychotic episodes) are seen

91. • Consider each person as either good or bad
and due to this splitting good person is
idealized and bad is devalued .
• Some clinicians use the concept of panphobia,
pananxiety , panambivalence and chaotic
sexuality to delineate these patient’s
characteristics .

92. Differential Diagnosis
• Schizophrenia
• Depressive and Bipolar disorders
• Other personality disorders –
- schizotypal and paranoid personality disorders
• Personality change due to another medical
condition
• Substance use disorder

93. Course and Prognosis
• Fairly stable , no progression towards
schizophrenia
• High incidence of major depressive episodes .

94. Treatment
• Psychotherapy –
- Difficult for therapists as patients regress
easily, act out their impulses and show labile
or fixed negative or positive transferences .
- Splitting defence mechanism causes patients to
alternately love and hate therapist

95. - A reality-oriented approach is more effective
then in-depth interpretations of the
unconscious.
- Behaviour therapy to control impulses and
anger
- Social skill training

96. • DIALECTICAL BEHAVIOR THERAPY (DBT)
- form of psychotherapy
- used for patients with parasuicidal behavior
• MENTALIZATION-BASED TREATMENT

97. • TRANSFERENCE-FOCUS PSYCHOTHERAPY
- modified form of psychodynamic
psychotherapy
- based on Otto Kernberg’s object relation
theory
- involved 2 major working processes -

98. I. Clarification –
- transference is analyzed more directly
- patient becomes quickly aware of his
distortions .
ii. Confrontation –
- therapists points out how these transferential
distortions interfere with interpersonal
relations towards others.

99. • Pharmacotherapy –
- Antipsychotics to control anger, hostility and
brief psychotic episode
- Antidepressants
- Benzodiazepines
- Anticonvulsants – Carbamazepine

100. Histrionic Personality Disorder
• Epidemiology –
• 1-3% of general population
• More in females
• Increase association with somatization and
alcohol use disorder.

101. Diagnosis and Clinical features
• Self-dramatization :
- emotional blackmail, angry scenes and
demonstrative suicidal attempts
• Easy suggestible and influenced by others
• Seek attention and excitement, easily bored
and have short-lived enthusiasms

102. • Shallow labile affect
• Inappropriately seductive
• Appear self centred and vain
• Marked capacity for self-deception
• Pathological liars and swindlers

103. • DSM-5 includes 2 additional criteria –
- speech excessively impressionistic
- consider relationships to be more intimate
then they are .

104. Differential Diagnosis
• Borderline personality disorder
• Brief psychotic disorder and dissociative
disorder may warrant a coexisting diagnosis

105. Course and Prognosis
• Patients are attention seekers and may get
into trouble with law, abuse substances and
act promiscuously .
• With age patient may show lesser symptom .

106. Treatment
• Psychoanalytically oriented psychotherapy ,
group or individual , is the treatment of
choice.
• pharmacotherapy –
- Antidepressants for depression and somatic
complaints
- Benzodiazepines for anxiety

108. Narcissistic personality disorder
• Listed in DSM-5
• Epidemiology –
• Occurs in 1-6% in general population
• 50-70% are males

109. Diagnosis and Clinical features
• Grandiose sense of self importance
• Boastful and pretentious
• Fantasizes about unlimited success, power,
beauty or brilliance
• Believes themselves special
• Requires excessive admiration

110. • Sense of entitlement to favours and
compliance
• Exploits others
• Lack empathy
• Envious of others and believes that others
envies them

111. Differential diagnosis
• antisocial personality disorders
• Mania or hypomania
• Substance use disorder

112. Course and prognosis
• Stable diagnosis
• More vulnerable to midlife crises

113. Treatment
• Psychotherapy :
- chronic and difficult to treat

114. Avoidant Personality Disorder
• Epidemiology :
- Seen in 2-3% of general population

115. Diagnosis and Clinical features
• Persistent and pervasive feeling of tension and
apprehension
• Feels insecure and lack self-esteem
• Feels socially inferior, unappealing and socially
inept
• Preoccupied with rejection, disapproval or
criticism

116. • Avoid risk and social activity
• Few close friends
• restraint in intimate relationships, due to fear
of being shamed or ridiculed
• inhibited in new personal situations, due to
feeling of inadequacy

117. Differential diagnosis
• Anxiety disorders (social phobia)
• Schizoid personality disorder
• Dependent personality disorder

118. Course and Prognosis
• Shy and avoidant during adolescence
• Able to function in a protected environment, if
their support system fails, they are subjected
to depression, anxiety and anger
• Incur social phobia in the course of illness

119. Treatment
• Psychotherapy –
• Depends on solidifying an alliance with
patients
- therapist encourage the patient to take
perceived risks
• Group therapy is helpful

120. • Pharmacotherapy –
- manage anxiety and depression
- beta blockers to manage autonomic
hyperactivity

121. Dependent Personality Disorder
Epidemiology –
• Prevalence – 0.6%
• More common in young children
• Increased rate in women
• Person with chronic physical illness in
childhood are more susceptible .

122. Diagnosis and Clinical features
• characterized by dependant and submissive
behavior
• Allows others to take responsibility for
important decisions in their lives
• Unduly complaint, but unwilling to make
direct demands
• Feels unable to care for themselves

123. - Lacking self-reliance , avoid responsibility and
need excessive help to make decisions
- experiences difficulty in initiating projects
- goes to excessive lengths to obtain help
- urgently seeks a supportive relationship

124. • In folie a deux, one member of the pair usually
has dependent personality disorder
• An abusive, unfaithful or alcoholic spouse may
be tolerated for long periods to avoid
disturbing the sense of attachment

125. Differential diagnosis
• Histrionic and borderline personality disorders
• Schizoid and schizotypal personality disorder
• Agoraphobia

126. Course and prognosis
• Impaired occupational functioning
• Limited social relationships
• Risks MDD if they lose the person on whom
they depend .

127. Treatment
• Psychotherapy –
• Treatment is often successful
• Insight-oriented therapy
• Behaviour therapy , assertiveness training,
family therapy and group therapy

128. • Pharmacology –
- treat anxiety and depression :
Benzodiazepines and SSRIs

129. Obsessive-Compulsive Personality
Disorder
• ICD-10 used the term ‘Anankastic’ personality
disorder .

130. • Epidemiology –
• Prevalence- 2-8%
• More common in men , diagnosed most often
in oldest sibling.

131. • Freud hypothesized that the disorder is
associated with the difficulties in anal stage of
psychosexual development.
• Defence mechanism used are –
- rationalization,
- intellectualization,
- reaction formation
- undoing.

132. Diagnosis & Clinical features
• Preoccupied with details, rules, order and
schedules
• Inhibiting perfectionism and make ordinary
work a burden
• Lack imagination and fail to take advantage of
opportunities
• High moral standards

133. • Excessively conscientious and judgemental
• Humourless and ill at ease when others are
enjoying
• Few friends
• Rigid and inflexible, avoiding change and
preferring a familiar routine
• Eager to please those whom they see as more
powerful then they are

134. • Stubborn and controlling
• Hoard objects and money
• Troubled by excessive doubt and caution,
leading to indecision .

135. Differential diagnosis
• Obsessive-compulsive disorder
• Hoarding disorder
• Delusional disorder

136. Course & Prognosis
• Variable and unpredictable
- some may develop obsession or compulsions
- some evolve into warm, open and loving
adults
- other can develop into schizophrenia or major
depressive disorder
• Personal lives may remain barren

137. Treatment
• Psychotherapy –
• Patient often aware of their suffering and seek
treatment on their own
• Free association and no directive therapy
• Treatment is often long and complex and
countertransference problems are common .

138. • Pharmacotherapy –
• SSRIs
- useful in obsessive-compulsive signs and
symptoms