Personality Disorders

Personality

The totality of emotional and

behavioral traits that characterize the person in day-to-day living under

ordinary conditions.

o Relatively stable and predictable.

Deeply ingrained, inflexible, and

maladaptive patterns of relating to

and perceiving both the environment

and themselves. influence cognition, affect, behavior

and interpersonal style. Cause subjective distress or

significant functional impairment.

prevalence is estimated between 10 and 20 percent in the general population

frequently labeled as aggravating, demanding, or parasitic

generally considered to have poor prognosis.

alloplastic (i.e., changing the external environment)

ego-syntonic (i.e., acceptable to the ego).

Having an understanding of

personality disorders will improve the

relationship, enhance compliance, and

reduce their stress.

Axis II pathology affects the

predisposition, presentation, course,

and prognosis of Axis I pathology.

Cluster A - odd, aloof features

paranoid schizoid schizotypal.

Cluster B - dramatic, impulsive, and erratic features

Borderline Antisocial Narcissistic histrionic.

Cluster C - anxious and fearful features

Avoidant Dependent Obsessive -compulsive

Cluster A personality disorders are more common in the biological relatives of patients with schizophrenia than in control groups

Antisocial personality disorder is associated with alcohol use disorders

Depression is common in the family backgrounds of patients with borderline personality disorder

A strong association is found between histrionic personality disorder and somatization disorder (Briquet's syndrome);

Patients with avoidant personality disorder often have high anxiety levels

Patients with obsessive-compulsive personality disorder show some signs associated with depression

Persons who exhibit impulsive traits also often show high levels of testosterone, 17-estradiol, and estrone

DSM-IV-TR General Diagnostic Criteria for a Personality Disorder A. An enduring pattern of inner experience and

behavior that deviates markedly from the expectations of the individual's culture. This 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, lability, and appropriateness of emotional response)

3. interpersonal functioning 4. impulse control

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.

C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.

E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.

F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).

Sigmund Freud suggested that personality traits are related to a fixation at one psychosexual stage of development.

Wilhelm Reich subsequently coined the term character armor to describe persons' characteristic defensive styles for protecting themselves from internal impulses and from interpersonal anxiety in significant relationships.

internal object relations - internal self-representations and object representations Through introjection, children internalize a parent or another

significant person as an internal presence that continues to feel like an object rather than a self.

Through identification, children internalize parents and others in such a way that the traits of the external object are incorporated into the self and the child owns the traits.

through externalization and projective identification, are played out in interpersonal scenarios in which others are coerced into playing a role in the person's internal life.

Defense Mechanisms :

Fantasy - seek solace and satisfaction within themselves by creating imaginary lives, especially imaginary friends. schizoid

Dissociation or denial is a Pollyanna-like replacement of unpleasant affects with pleasant ones. dramatizing and emotionally shallow; they may be

labeled histrionic personalities.

Isolation is characteristic of the orderly, controlled persons who are often labeled obsessive-compulsive personalities

Projection - patients attribute their own unacknowledged feelings to others. excessive faultfinding and sensitivity Counterprojection- Clinicians acknowledge and

give paranoid patients full credit for their feelings and perceptions; they neither dispute patients' complaints nor reinforce them, but agree that the world described by patients is conceivable.

Splitting - persons toward whom patients' feelings are, or have been, ambivalent are divided into good and bad.

Passive –aggression- turn their anger against themselves. includes failure, procrastination, silly or

provocative behavior, self-demeaning clowning, and frankly self-destructive acts.

Acting out- patients directly express unconscious wishes or conflicts through action to avoid being conscious of either the accompanying idea or the affect. Tantrums, apparently motiveless assaults, child

abuse, and pleasureless promiscuity

Projective identification - appears mainly in borderline personality disorder and consists of three steps : an aspect of the self is projected onto someone

else. tries to coerce the other person into identifying

with what has been projected the recipient of the projection and the projector

feel a sense of oneness or union.

Paranoid Personality Disorder

characterized by long-standing suspiciousness and mistrust of persons in general.

often hostile, irritable, and angry.

Bigots, injustice collectors, pathologically jealous spouses, and litigious cranks

prevalence - 0.5 to 2.5% of the general population.

more common in men than in women

hallmarks 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.

Psychotherapy is the treatment of choice

Pharmacotherapy is useful in dealing with agitation and anxiety.

Pimozide (Orap) has successfully reduced paranoid ideation in some patients.

Acknowledge mistakes. Be open and honest. Have a professional and not overly

warm style. Don’t confront. Set limits. Clearly explain procedures,

medications and results.

Schizoid Personality Disorder

display a lifelong pattern of social withdrawal.

discomfort with human interaction, their introversion, and their bland, constricted affect

eccentric, isolated, or lonely.

prevalence is 7.5 % of the general population

solitary interests and success at noncompetitive, lonely jobs that others find difficult to tolerate.

treatment is similar to that of those with paranoid personality disorder.

Understand their need for isolation. Minimize new contacts and intrusions. Maintain a quiet, reassuring, and

considerate interest in them. Don’t insist on reciprocal responses.

Schizotypal Personality Disorder

strikingly odd or strange

Magical thinking, peculiar notions, ideas of reference, illusions, and derealization

occurs in about 3 percent of the population

diagnosed on the basis of the patients' peculiarities of thinking, behavior, and appearance.

Similar to Schizoid PD. Misperceptions of physical symptoms

and treatment. Do not ridicule or judge. Respect their need for privacy.

Antisocial Personality Disorder

an inability to conform to the social norms that ordinarily govern many aspects of a person's adolescent and adult behavior.

prevalence is 3% in men and 1% in women.

onset of the disorder is before the age of 15.

Lying, truancy, running away from home, thefts, fights, substance abuse, and illegal activities

highly representative of so-called con men

notable finding is a lack of remorse for these actions; that is, they appear to lack a conscience.

self-help groups

firm limits are essential

Pharmacotherapy

Set firm limits. Try not to be manipulated. Have high level of skepticism. Be careful not to prescribe excessive

and/or unnecessary medications.

Borderline Personality Disorder

emotionally unstable personality disorder

1 to 2 percent of the population

twice as common in women as in men

almost always appear to be in a state of crisis.

Mood swings are common.

micropsychotic episodes - short-lived psychotic episodes

have tumultuous interpersonal relationships.

Shifts of allegiance from one person or group to another are frequent.

Be aware of and anticipate defenses. Often regress. Open and continuous communication with

staff. Stable and calm reaction. Gently confront. Set fair and consistent limits on acting out.

Histrionic Personality Disorder

excitable and emotional and behave in a colorful, dramatic, extroverted fashion

inability to maintain deep, long-lasting attachments

prevalence - 2 to 3%

high degree of attention-seeking behavior

display temper tantrums, tears, and accusations when they are not the center of attention or are not receiving praise or approval.

Seductive behavior is common

major defenses are repression and dissociation.

With age, show fewer symptoms, but because they lack the energy of earlier years, the difference in number of symptoms may be more apparent than real

Similar to Borderline PD.

Medical illnesses threaten their sense

of attractiveness and self-image.

Narcissistic Personality Disorder

characterized by a heightened sense of self-importance and grandiose feelings of uniqueness

than 1 percent in the general population

sense of entitlement is striking

handle criticism poorly and may become enraged when someone dares to criticize them

Interpersonal exploitiveness is commonplace

cannot show empathy, and they feign sympathy only to achieve their own selfish ends.

Handle criticism poorly. Become easily enraged. Medical illnesses can be a blow to their self-esteem. Reinforce that they are respected

and appreciated. Set limits on demanding behavior.

Avoidant Personality Disorder

show extreme sensitivity to rejection and may lead a socially withdrawn life.

not asocial and show a great desire for companionship, but they need unusually strong guarantees of uncritical acceptance.

prevalence - 1-10% of the general population

most striking aspect is anxiety

Hypersensitivity to rejection by others is the central clinical feature

main personality trait is timidity

Have patience and understanding. Medical illnesses may be

embarrassing. Minimize new and unfamiliar staff

contacts. Respond with a calm and reassuring

demeanor. Do not criticize them.

Dependent Personality Disorder

characterized by a pervasive pattern of dependent and submissive behavior.

cannot make decisions without an excessive amount of advice and reassurance from others.

more common in women than in men.

Pessimism, self-doubt, passivity, and fears of expressing sexual and aggressive feelings all typify the behavior

An abusive, unfaithful, or alcoholic spouse may be tolerated for long periods to avoid disturbing the sense of attachment.

Respect their feelings of attachment. Be careful when encouraging a patient

to change the dynamics of an abusive

relationship. When medically ill they may become

frustrated that they are not being helped. Be active in the treatment planning.

Obsessive-Compulsive Personality Disorder anancastic personality disorder

characterized by emotional constriction, orderliness, perseverance, stubbornness, and indecisiveness

essential feature of the disorder is a pervasive pattern of perfectionism and inflexibility

preoccupied with rules, regulations, orderliness, neatness, details, and the achievement of perfection.

lack flexibility and are intolerant.

capable of prolonged work, provided it is routinized and does not require changes to which they cannot adapt.

Give precise and rational explanations. Value efficiency and punctuality. Medical illnesses create a disruption in the

patient’s work, orderly lifestyle, and sense of control.

Acknowledge the importance of work, but point out how avoiding treatment may have harmful consequences.

Allow the patient to control his or her care as much as possible.

Provide them with information. Avoid power struggles. Understand their need for order and control.