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PERSONALITY DISORDER

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A condition comprising deeply ingrained and enduring behaviour patterns manifesting as inflexible responses to a broad range of personal & social situations.

They represent significant deviation from the way the average individual in a given culture perceives, thinks, feels and particularly relates to others.

Such behaviour patterns tend to be stable and are

associated with various degrees of subjective distress and problems in social functioning and performance.

WHO 1992.

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WHAT IS NORMALITY?

The following represent traits that ‘normal’ people possess to a greater degree than those diagnosed as ‘abnormal’.

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EFFICIENT PERCEPTION OF REALITY

Realistic appraisal of capabilities and what is going on around them. They do not consistently misperceive what others say and do…they do not overvalue their abilities…nor do they underestimate their abilities and shy away from everyday tasks.

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SELF-KNOWLEDGE

Well adjusted people have awareness of their own feelings. Although none of us can fully understand them, most do not hide important feelings from themselves. They have more self-awareness as a result.

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ABILITY TO EXERCISE VOLUNTARY CONTROL OVER

BEHAVIOUR

Confidence in personal ability to control behaviour. May act impulsively but can restrain sexual and aggressive urges when necessary. May fail to conform to social norms, but this is voluntary rather than the result of uncontrollable urges.

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SELF-ESTEEM & ACCEPTANCE

Appreciation of self-worth and acceptance by those around. Comfortable with others and able to react spontaneously in social situations. Don’t feel obligated to subjugate their opinions to those of a group.

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ABILITY TO FORM AFFECTIONATE RELATIONSHIPS

Formation of close & satisfying relationships with others. Sensitive to the feelings of others, and do not make excessive demands to gratify their own needs. Ability to reciprocate affection and don’t fear intimacy.

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PRODUCTIVITY

Ability to channel their abilities into productive activity. Have enthusiasm for life.

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WHERE THEY FIT INTO PSYCHIATRY?

An axis 1 disorder refers to the traditional mental illnesses such as:

Anxiety, Depression, Bipolar, Schizophrenia, Organic dementias

Personality disorders are categorised as axis 2 disorders

Viewing concrete symptoms in axis 2 is much more difficult than in axis 1.

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THEORIES OF HOW THEY DEVELOP

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1. PSYCHOANALYTIC

Personality serves as a host mechanism, comparable to the immune system, offering protection against the many psychological and interpersonal stresses of living, preventing symptom formation and breakdown.

There is also the façade – a false self, outside the true personality that enhances survival in a potentially hostile world e.g. the ability to say nothing, be tactful etc. [Millon 1981]

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Over compensation – an inborn tendency to counteract deficiencies and inadequacies through reparative striding. Undoing this over-compensation plays a key role in therapy, [Adler 1964].

Horney [1939] described three groups: 1. those who move towards people in their

relationships, compliant and self-effacing, self-esteem determined by others [dependent types]

2. those who move against others in relationships, aggressive seeing life as a struggle, seeking power and exploiting [sociopathic types]

3. those who move away from others and become detached, avoiding relationships and consequently lead restricted lives [avoidant, schizoid types]

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2. BIOLOGICAL PERSPECTIVE

Some evidence for underactive autonomic nervous system.

This may explain why some may crave excitement and fail

to respond to normally to threats and danger.

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3. PARENTAL INFLUENCE /LEARNING

THEORY Most children internalise their parents

values [which generally reflect the values of society] because they want to be like them. They fear the loss of love if they do not behave in accordance with these values.

A child who receives no love from either parent does not fear its loss; he does not identify with the rejecting parents and does not internalise their rules.

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A child may develop anti social personality if learning that punishment can be avoided by being charming, lovable and repentant.

Someone who is consistently able to avoid punishment by claiming to be sorry, promising never to do it again may fear that it is not the deed that counts but charm and the ability to act repentant.

A child who is protected from frustration or distress may have no ability to empathise with the distress of others.

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4. CHILDHOOD ABUSE Strong evidence for association between borderline

personality and sexual abuse Evidence also for link between sexual abuse and

any personality disorder diagnosis. Beware false memory syndrome though. Most children exposed to a specific adversity do not

develop an adult mental disorder. Multiple adversities have a cumulative effect though.

Timing is not crucial. Traditional wisdom that the younger the age of trauma, the more damaging, is not always necessary. A bitter divorce in adolescence may outweigh a separation in infancy.

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TYPES

Cluster A = suspicious Cluster B = emotional and

impulsive Cluster C = anxious

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SUSPICIOUS

PARANOID - suspicious…feel others are against them…sensitive to rejection…hold grudges

SCHIZOID – emotionally cold…prefer own company…have fantasy world

SCHIZOTYPAL – odd ideas…difficulties with thinking…lack of emotion.. may see or hear strange things

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EMOTIONAL AND IMPULSIVE

ANTISOCIAL, DISSOCIAL – no care for feelings of others…easily frustrated….aggressive…..avoid intimacy…act on spur of moment…don’t feel guilty.

BORDERLINE, EMOTIONALLY UNSTABLE – impulsive…low self-worth….self-harm…feel empty….make and break relationships….feel paranoid.

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HISTRIONIC – over dramatic…self-centred….show strong emotions which change and don’t last…suggestible…crave new things, excitement.

NARCISSISTIC – strong sense of self-importance…dream of power, success….crave attention of others, no warm feelings in return…exploit, manipulate others.

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ANXIOUS OBSESSIVE-COMPULSIVE – worry,

doubt…perfectionist….rigid….worry about doing wrong thing…..high moral standards….judgemental…sensitive to criticism.

AVOIDANT – anxious, tense….insecure, inferior….have to be liked, accepted…sensitive to criticism.

DEPENDENT – passive…rely on others to make decisions…feel incompetent…feel abandoned by others.

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SPECIAL POPULATIONS

PARASUICIDE 75% men 60% women have

personality disorder [explosive type mainly] Casey 1989.

46% patients have anxious, paranoid type Haw 2001.

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SUICIDE 37% emotionally unstable [Cheng

2000]. 44% antisocial, avoidant,

dependent [Foster 1997].

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PRISON Evaluating the condition in prison runs the risk of assuming

that, because of antisocial behaviour, it is inevitably present.

Separating the criminal behaviour from underlying traits [e.g. callousness] is crucial if personality disorder is to be meaningfully evaluated.

Prison studies have shown a high prevalence [39 – 76%] of antisocial type.

Another study identified personality disorder in 63% of male remand prisoners, 49% sentenced prisoners and 31% of female prisoners. Paranoid was second most common category in males, borderline in women, [Singleton 1998].

Remand or sentenced prisoners are 10 times more likely to have antisocial personality disorder than counterparts in general population, [Coid 1993].

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GENDER BIAS Paranoid male > female Schizoid male > female Anti social male > female Avoidant male = female Narcissistic male >>>female Obsessive male >> female Histrionic female > male Dependent female > male Borderline female >>>male

Hartig 1998.