PERSONALITY DISORDERS Biological factors

 Impulsive traits   testosterone, 17 estradiol, estrone

Personality   MAO  schizotypal & more social
 observable behavior AND subjective inner experience  smooth pursuit eye movements  saccadic (jumpy) in
(public & private aspects) px who are introverted,  self esteem, withdrawn &
 passive/ aggressive schizotypal
 ambitious, religious, friendly  endorphins  ~morphine, analgesia, suppresion of
 qualifications of a personality d/o implies certain arousal
predictions about how a person will behave under   endorphins  phlegmatic persons
certain circumstances.   5HIAA (serotonin metabolite)  suicidal, impulsive,
 Px are more likely to refuse help & deny problems aggressive
 Symptoms are   5HT (using Prozac)   depression, impulsiveness,
 Alloplastic  able to adapt to & alter external rumination & produce sense of well being
environment   dopamine (using psychostimulants like amphetamine)
 Ego syntonic  acceptable to the ego  induces euphoria
 Px do NOT feel anxiety about their maladaptive  EEG changes  antisocial & borderline (slow wave)
behavior
Psychoanalytic factors
 DSM IV TR definition:  Freud
 Enduring subjective experiences & behavior that  Fixation at one psychosexual stage of dvlpt
deviate from cultural standards (of the individual)  Oral character  passive & dependent
 2 or more of: (dependence on others for food)
 Cognition  ways of percieving & interpreting  Anal character  subborn, parsimonious, & highly
self, other people & events conscientious (struggle over toilet training)
 Affectivity  range, intensity, lability, &
appropriateness of emotional response  Reich
 Interpersonal functioning  Character armor  person’s defensive style to protect
 Impulse control themselves from internal mpulses & interpersonal
 Rigidly (inflexible) pervasive & maladaptive anxiety
 Adolescent/ early adulthood onset  Paranoid  uses projection
 Stable  Schizoid  associated with withdrawal
 Lead to unhappiness & impairment (produce fxnal  When the defenses work, the px master their
impairment or subjective distress) feelings therefore viewing their behavior as ego
 Not a direct cause of another mental d/o or syntonic (creating no distress to them even if it
substance (medication/drugs) adversely affects others)
 Cluster A  px percieve as odd & eccentric
 Paranoid  Internal object relations
 Schizoid  Introjection  children internalize a parent or
 Schizotypal another significant person as an internal presence
 Cluster B  dramatic, emotional & erratic that continues to feel like an object rather than a
 antisocial self
 borderline  Child owns the traits of the external object
 histrionic
 narcissistic  Defense mechanisms  4 lodestars of inner life
 Cluster C  anxious, fearful (instinct (wish/need), reality, important persons,
 Avoidant conscience)
 Dependent  Fantasy  px schizoid, labeled as eccentric, lonely
 Obsessive compulsive or frightened, seek solace & satisfaction within
 Not otherwise specified themselves by creating imaginary lives/friends; fear
 Passive aggressive of intimacy
 Depressive  Dissociation / Denial  polyanna like replacement
of unpleasant affects w/ pleasant ones
Etiology  Isolation  orderly, controlled persons who are
 Cluster A – occur more commonly in biological often labeled OC
relatives of px w/ schizophrenia (esp schizotypal);  Projection  px attribute their own
there is less correlation between paranoid or schizoid unacknowledged feelings to others; excessive
personality d/o to schizophrenia faultfinding & sensitivity to criticism
 Cluster B – have more relatives with mood disorders;  Splitting  good and bad
have overlap symptoms  Passive aggression  turn their anger against
 Antisocial  alcohol themselves (masochism)
 Borderline  depression (also have abn DST)  Acting out  tantrums, child abuse, pleasureless
 Histrionic  somatization (Briquet’s) promiscuity
 Cluster C –  Projective identificaton  @ borderline personality
 Avoidant  anxiety
 OC  monozygotic; depresion (short REM & abn
dexamethasone suppression tests : DST )
pArAnOiD personality d/o
 Long standing suspiciousness & mistrust of persons
 Refuse responsibility for their own feelings and assign
responsibility to others
 Hostile, irritable , angry
 Bigots, injustice collectors, pathologically jealous
spouses
 0.5 – 2.5% @ general population
 can often pull themselves together & appear
undistressed
 M > F, NO familial pattern
 DSM IV TR
 Pervasive distrust & suspiciousness of thers such
that their motives are interpreted as malevolent
 Early adulthood, w/ 4 or more
 Suspects (w/o basis) that others are exploiting,
harming or decieving
 Have unjustified doubts about the loyalty or
trustworthiness of friends or associates
 Reluctant to confide in others because of
unwarranted fear that the information will be
used maliciously against him
 Reads hidden demeaning or threatening
meanings into benign remarks or events
 Bears grudges (unforgiving)
 Percieves attacks on his character/reputation
& quick to react angrily and counterattack
 Recurrent suspicion regarding fidelity of
spouse/ sexual partner
 Formal manner, muscular tension, need to scan
environment for clues, humorless, serious
 Arguments premises are false but goal directed &
logical
 Ideas of reference, projection, prejudice
 In others, it is a harbinger of schizophrenia
 TX
 Psychotherapy  TX OF CHOICE
 Pharmacotherapy
 Diazepam (valium)  antianxiety
 Haloperidol (haldol)  antipsychotic, to
manage sever agitation or quasi-delusional
thinking
 Pimozide (orap(  antipsychotic,  paranoid
ideation
ScHiZOiD personality d/o
 Lifelong pattern of social withdrawal
 Discomfort with human interaction, introverted w/
bland constricted affect
 Eccentric, isolated or lonely
 DSM IV TR
 Pervasive pattern of detachment from social relationships and
a restricted range of expression of emotions in interpersonal
settings
 Begins early adulthood, w/ 4 or more…
 Neither desires nor enjoys close relationships (inc family)
 Chooses solitary activities
 Little interest in sexual experiences
 Takes pleasure in few activities
 Lacks close friends or confidants (other than first degree
relatives)
 Indifferent to praise or criticism of others
 Shows emotional coldness, detachment or flattened affect

 7.5 % general pop
 “sex ratio is unknown” but some studies say 2:1, M>F
 Gravitate towards solitary jobs that involve little or no
contact w/ others (night work)
 Can’t tolerate eye contact, eager for the interview to
end, fearful, give short answers, last to be aware of
changes in popular fashion.. etc.
 Do not have schizophrenic relatives
 Have successful if isolated work histories
 Onset early childhood??? –p805
 Long lasting, but not necessarily lifelong
 TX
 Psychotherapy
 Px may become devoted, if distant pxs
 Pharmacotherapy
 Antipsychotics, antidepressants &
psychostimulants
 Serotonergic agents --> make px less sensitive
to rejection
 Benzodiazepines --> help  interpersonal
anxiety
ScHiZoTyPaL personality d/o
 Odd, strange.. w/ magical thinking, peculiar notions,
ideas of reference, ilusions & derealization
 3 % gen pop
 sex ratio unknown
  association w/ schizophrenic relatives

 DSM IV TR
 Pervasive pattern of social & interpersonal deficits
marked by acute discomfort w/ & reduced capacity for
close relationships
 Cognitive/ perceptual distortions & eccentricities of
behavior
 Beginning by early adulthood w/ 5 or more …
 Ideas of reference (excluding delusions of
reference)
 Odd beliefs or magical thinking w/ is inconsistent
w/ norms (superstition, clarivoyance, telepathy,
sixth sense; in children, bizarre fantasies &
preoccupations)
 Suspiciousness or paranoid ideation
 Inappropriate or constrictd affect
 Behavior or appearnce that is odd, eccentric or
peculiar
 Lack of close friends or confidants other than first
degree relatives, excessive social anxiety that dsnt
diminish with familiarity & tends to be associated
w/ paranoid fears rather than negative judgements
about self.
 Absence of psychosis (difference between schizotypal
& schizophrenia)
 If psychosis is presnet, they are brief & fragmentary
 10% eventually commit suicide
 Tx
 Psychotherapy
 Pharmacotherapy
 Antipsychotic --> ideas of reference, illusions
 Antidepressants
AnTiSoCiaL personality d/o  DSM IV TR
 Inability to conform to the social norms  Pervasive pattern of instability of interpersonal relationships,
 NOT synonymous w/ criminality self image, and affets & marked impulsivity
 Early adulthood
 3% M > 1% F
 5 or more of..
  poor urban areas & mobile residents  frantic efforts to avoid real or imagined abandonment
 boys from large families  unstable & intense interpersonal relationships
 onset before 15 (boys earlier) characterized by alternating between extremes of
 in prison, 75% idealization & devaluation
 familial pattern, 5% more comon in 1st degree relatives  identity disturbance: markedly & persistently unstable
self image or sense of self
 Mask of sanity  impulsivity in at least 2 areas that are potentially self
damaging
 Hervey Cleckley
 spending, sex, subst abuse, reckless driving, binge
 Px may appear composed & credible, but beneath eating
the veneer there is tension, hostility, irritability &  recurrent suicidal behavior, gestures, or threats or self
rage mutilating behavior
 Stress interview (confrontation) may be necessary  affective instability due to a marked reactiviyt of mood
 intense episodic dysphoria, irritability, anxiety
 DSM IV TR  lasting few hrs only
 Pervasive pattern of dsregard for and violation of rights  chronic feelings of emptiness
 inappropriate intense anger or difficulty controlling anger
of others occuring since age 15 years
 frequent displays of temper, constant anger,
 3 or more of.. recurrent physical fights
 failure to conform to social norms w/ respect to  transient, stress related paranoid ideation or severe
lawful behaviors (repeatedly performing acts that dissociative symptoms
are grounds for arrest)
 deceitfulness, (repeated lying, use of aliases, or  shortened REM latency, sleep continuity disturbance,
conning others for personal profit or pleasure) abnormal DST, abn thyrotropin releasing hormone
 impulsivity or failure to plan ahead results
 irritability and aggressiveness, (repeated physical  also seen in depressive d/o
fights or assaults)  appear in a state of crisis
 reckless disregard for safety of self or others  mood swings common
 consistent irresponsibility (repeated failure to  short lived psychotic symptoms (micropsychotic
sustain consistent work behavior or honor financial episodes) --> difference from schizophrenia
obligations)  cannot tolerate being alone
 lack of remorse (indifference to having hurt,  lack of consistent sense of identity (identity diffusion)
mistreated, or stolen from another)  projective identification
 at least 18 y/o  Otto Kernberg
 evidence of conduct d/o w/ onset before age 15 y/o  Defense mechanism
 not during schizophrenia or manic episode  Intolerable aspect of the self are projected onto
another; the other person is induced to play the
 unremitting course --> reaches peak at late projected role & the two persons act in unison
adolescence  Rorschach test --> unstructured projective test which
 have somatization disorders, depression, alcohol use, shows the deviant processes
substance abuse  Distortion of relationships by considering a person as
 Tx either all good or all bad.
 Psychotherapy --> except immobilized px 
 When px are among peers, their lack of  fairly stable
motivation for change disappears  no progression towards schizophrenia, but  incidence
 Pharmacotherapy of MDD
 Psychostimulants  Dx before age 40 (when many life cycle choices are
 Methylphenidate --> attention made)
deficit/hyperactivty d/o  Tx
 Antiepileptic drugs --> control impulsive  Psychotherapy
behavior  For best results add pharmacotherapy
 Carbamazepine  Dialectical behavior therapy
 Valproate  Esp those w/ parasuicidal behavior (freq
  adrenergic antagonist -->  aggresion cutting)
 Pharmacotherapy
BoRdErLiNe personality d/o  Antipsychotics – control anger, hostility, &
 on the border between neurosis & psychosis brief psychotic episodes
 ambulatory schizophrenia  Antidepressants –
 as-if personality d/o (by Deutsch)  MAOI – modulate impulsive behavior
 pseudoneurotic schizophrenia (by Hoch & Politan)  Benzodiazepines –
 psychotic character d/o (by Frosch)  Alprazolam – help anxiety & depression
 emotionally unstable personality d/o (ICD10) (caution: disinhibition)
 1-2% gen pop  Anticonvulsants
 F (2x) > M  Carbamazepine – improve global fxning
  prevalence of MDD, alcohol use, subst abuse  SSRI

HiStRiOniC personality d/o
 Excitable, emotional, behave in a colorful, dramatic,
extroverted fashion
 Inability to maintain deep, long-lasting attachments
 2-3% gen pop
 10-15% out px, in px (structured assessment)
 F>M
 Assoc w/ somatization & alcohol use
  preoccupied w/ fantasies of unlimited success,
 DSM IV TR
 Pervasive pattern of excessive emotionality & attention
seeking
 Early adulthood
 5 or more of…
 uncomfortable in situations in w/c he or she is not
the center of attention
 interaction w/ others is often characterized by
inappropriately sexually seductive or provocative
behavior
 displays rapidly shifting and shallow expression of
emotions
 consistently uses physical appearance to draw
attention to self
 has a style of speech that is excessively
impressionistic and lacking in detail
 shows self dramatization, theatrically &
exaggerated expression of emotion
 is suggestible (easily influenced)
 considers relationships to be more intimate than
they actually are.
 Cooperative, eager to give a detailed hx
  gestures & dramatic punctuations in conversations
 freq slip of the tongue, colorful language
 high degree of attention seeking behavior, exagg
thoughts and feelings & make everything sound more
impt than it really is, need for reassurance is endless
 seductive behavior is common but may have
psychosexual dysfxn (women may be anorgasmic & men
may be impotent)
 major defenses
 repression & dissociation
 reality testing becomes impaired under stress
 unaware of their own real feelings (cannot explain
their motivations)
 sensation seekers --> may get into trouble w/ the law,
subst abuse, act promiscuously
 tx
 psychotherapy
 psychoanalytically oriented (grp/indiv) :
TREATMENT OF CHOICE
 pharmacotherapy --> adjunct
 antidepressants – depression & somatic
complaints
 antianxiety –
 antipsychotics – derealization & illusion
NaRciSSisTiC personality d/o
 heightened sense of self importance & grandiose
feelings of uniqueness
 2-16% clinical pop
 <1% gen pop
 may impart unrealistic sense of omnipotence, beauty,
talent to their children
 expect special tx
 handle criticism poorly & may become enraged (or
indifferent) when someone dares to criticize them
 ambitious to achieve fame & fortune
 DSM IV TR
 Pervasive pattern of grandiosity (fantasy/ behavior),
need for admiration, lack of empathy
 Early adulthood
 5 or more of..
 grandiose sense of self importance (exagg
achievements & talents, expects to be recognized
as superior w/o commensurate achievements)
power, brilliance, beauty or ideal love.
 Believes that he or she is “special” & unique and
can only be understood by or should associate with,
other special or high status people (institutions)
 Req excessive admiration
 Has a sense of entitilement (unreasonable
exectations of especially favorable tx or automatic
compliance w/ his/her expectations
 Interpersonally exploitative (takes advantage of
others to achieve his or her own needs)
 Lacks empathy: unwilling to recognize or idenitfy
w/ the feelings & needs of others
 Is often envious of others or believes that others
are envious of him or her
 Shows arrogant, haughty behaviors or attitudes
 Chronic, dificult to tx
 Aging is handled poorly (more vulnerable to midlife
crisis)
 Tx
 Psychotherapy
 Pharmacotherapy
 Lithium – if w/ mood swings
AvOiDaNt personality d/o
 Extreme sensitivity to rejection (socially withdrawn or
shy but not asocial  bec they have desire for
companionship)
 BUT need strong guarantee of uncritical acceptance
 Inferiority complex
 Anxious personality d/o (ICD 10)
 1-10% gen pop
 timid temperament  more prone
 most striking aspect  anxiety about talking to an
interviewer

 DSM IV TR
 Pervasice pattern of social inhibition, feelings of
inadequacy, and hypersensitivity to negative
evaluation
 Early adulthood
 4 or more of..
 avoids occupational activities that involve
significant interpersonal contact (because of fears
of criticism, disapproval or rejection)
 unwilling to get involved w/ people unless certain
of being liked
 shows restraint w/in intimate relationships because
of the fear of being shamed or ridiculed
 preoccupied w/ being criticized or rejected in
social situations
 inhibited in new interpersonal situations because of
feelings of inadequacy
 views self as socially inept, personally unappealing
or inferior to others
 unusually reluctant to take personal risks or to
engage in any new activities because they may
prove embarassing
 central clinical feature = hypersensitivity to rejection
 main personality trait = timidity
 afraid to speak in public or make requests
 apt to misinterpret comments as derogatory/ ridiculing
 px w/ dependent personality d/o have a greater fear
of being abandoned or unloved than those w/ avoidant
personality d/o
 able to fxn in a protected environment (stable family
support system)
 phobic avoidance is common
 tx
 psychotherapy
 pharmacotherapy
  adrenergic antagonists
 atenolol – manage ANS hyperactivity
 serotonergic agents – help rejection sensitivity
DePeNdEnT personality d/o
 subordinate their own needs to those of others
 get others to assume responsibility for major areas of
their lives
 lack self confidence
 experience intense discomfort when alone for more
than a brief period
 passive dependent personality
 (Freud)
 oral-dependent personality dimension
characterized by dependence, pessimism , fear of
sexuality, self doubt, passivity, suggestibility & lack
of perseverance
 F>M
 2.5% of all personality d/o
 more common in young children
 more prone  persons w/ chronic physical illness
 (unable to complete a project because his/her own overly
 DSM IV TR
 Pervasive and excessive need to be taken cared of that leads
to submissive & clingng behavior & fears of separation
 Early adulthood w/ 5 or more of…
 Difficulty making everyday decisions w/o excessive
amount to advice/ reassurance
 Needs others to assume responsibility for most major
areas of life
 Has difficulty expressing disagreement w/ others (fear of
loss of support or approval); doesNOT include realistic
fears of retribution
 Difficulty initiating projects/things by self (due to lack of
self confidence in judgement or abilities rather than lack
of motivation)
 Goes to excess lengths to obtain nurturance & support
from others to the point of volunteering to do things that
are unpleasant
 Feels uncomfortable or helpless when alone bec of exagg
fears of being unable to care for himself or herself
 Urgently seeks another relationship as a source of care &
support when a close relationship ends
 Unrealistically preoccupied w/ fears of being left to take
care of oneself
 Folie a deux
 Shared psychotic d/o
 One member of the pair usually suffers from
dependent personality d/o
 The submissive partner takes on the delusional
system of a more aggressive, assertive partner on
whom he or she depends
 An abusive, unfaithful or alcoholic spouse may be
tolerated to avoid disturbing the sense of attachment
 DDX:
 Dependence is towards a person with a long-term
relationship
 Not manipulative
 Occupational fxning is impaired (cannot act
independently & w/o close supervision)
 Many suffer physical & mental abuse because they
cannot assert themselves.
 TX:
 Psychotherapy
 Pharmacotherapy
 Imipramine  for the separation anxiety
ObSeSSiVe CoMpULsiVe personality d/o
 Emotional constriction, orderliness, perseverance,
stubborness & indecisiveness
 Essential feature: pervasive pattern of perfectionism &
inflexibility
 ICD 10: Anancastic personality d/o
 M>F; most often in oldest children
 Backgrounds: harsh discipline
 Freud: difficulties in the anal stage (around age 2)
 Stiff, formal, rigid demeanor, constricted affect, lack
spontaneity, serious mood, answers are unusually
detailed
 Defenses: rationalization, isolation, intellectualization,
reaction formation, undoing

 DSM IV TR
 Pervasive pattern of preoccupation w/ orderliness,
perfectionism, & mental & interpersonal control at the
expense of inflexibility, openness & efficiency, beginning by
early adulthood
 4 or more of…
 preoccupied w/ details, rules, lists, order, organization,
schedules to the extent that the major point of the
activity is lost.
 Shows perfectionism that interferes with task completion
strict standards are not met)
 Excessively devoted to work & productivity (exclude
leisure activities & friendship; not accounted by obvious
economic necessity)
 Overconscientious, scrupulousm inflexible about matters
of morality, ethics, or values (not accounted by
religious/cultural identification)
 Unable to discard worn out or worthless objects even
when they have no sentimental value
 Reluctant to delegate tasks or to work with others unless
they submit exactly to his way of doing things
 Adopts a miserly spending lifestyle towards both self &
others (views money as something to be hoarded for
future catastrophes)
 Rigidity & stubborness
 However, eager to please those whom they see as
more powerful than they are & carry out these
persons’ wishes in an authoritarian manner.
 Fear of making mistakes  indecisive & ruminate
about in making decisions
 Depressive d/o (late onset)  common
 Tx:
 Psychotherapy  aware of their suffering & seek
treatment on their own
 Tx is long & complex, countertransference is a
problem
 Pharmacotherapy
 Clonazepam  BZD w/ anticonvulsant use (OK
in sever OCD but, use in personality d/o
unknown??? –p816)
 Clomipramine, etc…
Personality d/o NoT oThErWiSe sPeCiFiEd
 PaSsiVe AgGrEsSiVe personality d/o
 DSM IV TR
 Pervasive pattern of negativistic attitudes & passive
resistance to demands for adequate performance, beginning
by early adulthood
 4 or more
 passively resists fulfilling routine social & occupational
tasks
 complains abt being misunderstood & unappreciated by
others
 sullen & argumentative
 unreasonably criticizes & scorns authority
 expresses envy & resentment towards those apparently
more fortunate
 voices exaggerated & persistent complaints of personal
misfortune
 alternates between hostile defiance & contrition

 dEpPrEsSiVe personality d/o

 DSM IV TR
 Pervasive pattern of depressive conditions & behaviors
beginning by early adulthood (chronic & lifelong)
 5 or more
 usual mood is dominated by dejection, gloominess,
cheerlessness, joylessness, unhappiness
 self concept centers around beliefs of inadequacy,
worthlessness & low self esteem
 critical, blaming, derogatory towards self
 brooding, given to worry
 negativistic, critical, judgemental towards others
 pessimistic
 prone to feeling guilty or remorseful

 SaDoMaSoChiStiC personality d/o

 Sadism  desire to cause others pain by being either sexually
abusive or generally physical or psychologically abusive
 Masochism  achievement of sexual gratification by inflicting
pain on self

Personality change due to a general medical condition

 Head trauma, CVD , Cerebral tumors , Epilepsy ,
Huntington’s , MS , Endocrine , Metal poisoning ,
Neurosyphilis , AIDS , *Anabolic Steroids

PSYCHOBIOLOGICAL MODEL OF TREATMENT

 Harm Avoidance
 Heritable bias in the inhibition of behavior in
response to signals of punishment & reward
 Novelty Seeking
 Activation in response to novelty, approach to
signals of reward & active avoidance punishment
 Reward Dependence
 Maintenance of behavior in response to cues of
social reward.
 Persistence
 Maintenance of behavior despite frustration,
fatigue, and intermittent reinforcement.

Lisa Traboco