Personality Disorders

Personality refers to all the ways someone shapes and adapts in a unique way to an ever -changing internal and external environment.
• Personality disorder symptoms are ego-syntonic (acceptable to the ego) and alloplastic (adapt by trying to alter the external environment rather than
themselves)
• Persons with PDs do not feel anxiety about their maladaptive behavior.

HALLMARKS: Excessive suspiciousness and distrust of

others
• expressed as a pervasive tendency to interpret the
actions of others as deliberately demeaning, malevolent,
threatening, exploiting, deceiving
○ this tendency begins in early adulthood
FEATURES:
• expect to be exploited or harmed by others
• dispute, without justification, friends'/associates' loyalty
and trustworthiness
• pathologically jealous and question fidelity of spouses or
sexual partners
• ideas of reference
• logically defended illusions

DEFENSE MECH: PROJECTION

• They externalize their own emotions
• They attribute to others the impulses and thoughts
they cannot accept in themselves
PSYCHIATRIC EXAM:
• formal in their style
• act baffled about having to seek psychiatric help
• muscular tension/inability to relax
• need to scan environment for clues
• manner is severe and humorless
• some premises of their arguments may be false but
speech is goal-directed and logical
• THOUGHT CONTENT: evidence of projection, prejudice,
ideas of reference

FEATURES:

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 FEATURES:
• cold and aloof
• display a remote reserve and show no involvement ni
everyday events and concerns of others
• quiet, distant, seclusive, unsociable
• pursue their own lives with remarkably little need or
longing for emotional ties
• last to be aware of changes in popular fashion

LIFE HISTORY:
• reflect solitary interests and success at noncompetitive,
lonely jobs that others find difficult to tolerate
• sexual lives exist exclusively in fantasy and may
postpone mature sexuality indefinitely
• lifelong inability to express anger directly
• lack close friends
• indifferent to praise and criticism
• appear self-absorbed and lost in daydreams, but they
have an average capacity to recognize reality

PSYCHIATRIC EXAM:
• ill at ease
• rarely tolerate eye contact and seems eager for
interview to end
• AFFECT: constricted, aloof, inappropriately severe
○ underneath the aloofness, there is fear
• patients find it challenging to be light-hearted
○ efforts at humor may seem adolescent and off
the mark
• speech is goal-directed but gives short answers to
avoid spontaneous conversations
○ use unusual figures of speech: odd metaphors
○ fascination with inanimate objects or
metaphysical constructs
• sensorium intact, memory functions well
• proverb interpretations abstract

FEATURES:
• pervasive discomfort with and inability to maintain close
relationships, plus eccentric behavior
• demonstrate peculiarities of thinking, behavior,
appearance
• history taking may be difficult
• exhibit disturbed thinking and communicating
• frank thought disorder is absent
• speech is distinctive or peculiar and may have meaning
only to them
• superstitious and claims powers of clairvoyance, thought,
and insight
• inner world contain vivid imaginary relationships and
child-like fears and fantasies
• poor interpersonal relationships and thus are isolated
• under stress, patients may decompensate and have brief
psychotic symptoms
○ in severe cases, patients may exhibit anhedonia and
severe depression

HALLMARKS:
• pervasive disrespect for and infringement on the rights of
others
• person has to be 18 y/o or older and;
• have demonstrated this behavior since 15 y/o and;
• have demonstrated evidence of conduct disorder before the
age of 15 y/o
○ conduct disorder:
▪ involves a repetitive and persistent pattern
behavior in w/c they violate the fundamental
rights of others or major age-appropriate social

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 age of 15 y/o
○ conduct disorder:
▪ involves a repetitive and persistent pattern
behavior in w/c they violate the fundamental
rights of others or major age-appropriate social
rules
FEATURES:
• seem to be normal and appear charming and ingratiating
• history reveals disordered life functioning
○ lying, truancy, running away from home, thefts, fights,
substance abuse and illegal acts beginning from
childhood
• can be manipulative and demanding
• have heightened sense of reality testing
• have excellent verbal intelligence

REPRESENTATION:
• CON MEN
• manipulative and talk others into participating in schemes for easy money or
for fame and notoriety
• promiscuity, spousal abuse, child abuse and drunk driving are frequent
events in their lives
• NOTABLE FINDING: lack of remorse, lack of conscience
• DURING INTERVIEW: appear composed and credible but actually have
tension, hostility, irritability, rage
○ STRESS INTEVIEW: clinician vigorously confronts patient with
inconsistencies in their histories, necessary to reveal pathology
○ DIAGNOSTIC WORK-UP:
▪ neurologic exam: abnormal EEG results, soft neurologic signs ->
brain damage in childhood

FEATURES:
• almost always appear to be in a state of crisis
• frequent mood swings
• argumentative in one moment, depressed th next, later
complain of having no feelings
• have short-lived psychotic episodes and symptoms are
fleeting, circumscribed or questionable
• behavior highly unpredictable
• achievements rarely at the level of their abilities
• painful nature of their lives reflects in their repetitive self-
destructive acts
• patients may slash wrists and self-mutilate to elicit help from
others, to express anger, to numb overwhelming affect
• tumultuous relationships, dependent on those whom they
are close
○ when frustrated, can express enormous anger toward
intimate friends
• cannot tolerate being alone
○ prefer a frantic search for companionship
○ to assuage loneliness, they accept stranger as a friend
o behave promiscuously
• complain of emptiness and boredom and lack consistent
sense of identity
○ identity diffusion

DEFENSE MECHANISM: PROJECTIVE IDENTIFICATION

• patient projects intolerable aspects of themselves onto
another person, inducing them to play projected role, and
the 2 act in unison

PSYCHE FUNCTIONS:
• distort their relationships by considering each person as all good or all bad
○ see persons as either nurturing attachment figures or as hateful,
sadistic figures who deprive them of security needs and threaten them
with abandonment whenever they feel dependent
○ from this splitting, good person is idealized and bad person devalued
• shifts of allegiance are frequent
• panphobia, pan-anxiety, pan-ambivalence, chaotic

FEATURES:

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 FEATURES:
• HIGH DEGREE ATTENTION SEEKING BEHAVIOR
• exaggerate thoughts and feelings
• display temper tantrums, tears, accusations when not center
of attention or not receiving praise or approval
• seductive behavior is typical in both sexes
○ sexual fantasies about persons with whom patients are
involved are common, but patients are inconsistent
about verbalizing these fantasies
▪ they're coy and flirtatious rather than sexually
aggressive
○ psychosexual dysfunction: anorgasmia
○ act on sexual impulse
○ vain, self-absorbed, fickle
○ their deep dependence make them overly trusting and
gullible

DEFENSE MECHANISMS: REPRESSION & DISSOCIATION

• patients are unaware of rue feelings and cannot explain their
motivations
• UNDER STRESS, reality testing quickly becomes impaired
INTERVIEWS:
• generally cooperative and eager to give detailed history
• gestures and dramatic punctuation in conversation
• frequent slips of the tongue & colorful language
• typical affective display but when pressed, they respond with surprise, indignation
or denial
• COGNITIVE EXAM: usually normal, may show lack of perseverance on
arithmetic/concentration tasks
○ + patient forgetfulness of affect-laden material

FEATURES:
• grandiose sense of self-importance
• handle criticism poorly
• ambitious to achieve fame and fortune
• relationships are tenuous
• refusal to obey conventional rules of behavior
• interpersonal exploitativeness common
• can't show empathy ad feign sympathy to achieve selfish
ends
• fragile self-esteem -> susceptible to depression
• stresses produced by their behavior:
○ interpersonal difficulties
○ occupational problems
○ rejection
○ loss

FEATURES:
• CENTRAL FEATURE: hypersensitivity to rejection
• PRIMARY PERSONALITY TRAIT: timidity
• desire warmth and security of human companionship
○ avoid relationships by fear of rejection
• express uncertainty, lack self-confidence, speak in self-effacing
manner
• afraid to speak up in public
• misinterpret others' comments as derogatory or ridiculing
• refusal to requests leads to withdrawal from others and feel
hurt
VOCATIONAL SPHERE:
• take jobs on the sidelines
• rarely attain personal advancement or exercise much
authority
• unwilling to enter relationships unless they have strong
guarantee of uncritical acceptance
• no close friends

INTERVIEW:
• Most striking aspect is ANXIETY about talking with an
interviewer
• nervous and tense manner wax and wane

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 • nervous and tense manner wax and wane
• may regard interviewer's comments & suggestions as
criticism

FEATURES:
• pervasive pattern of dependent & submissive behavior
• cannot make decisions w/o significant advice and
encouragement
• avoid positions of responsibility
○ become anxious when assuming leadership roles
• on their own, difficulty to persevere at tasks
○ but, find it easy to perform tasks for someone else
• does not like to be alone
○ relationships distorted by need to be attached to
another person
• FOLIE A DEUX
○ shared psychotic d/o
○ one member has dependent PD, becomes a submissive
partner
▪ takes on the delusional system of the more
aggressive, assertive partner
• pessimism, self-doubt, passivity, fears of expressing sexual
and aggressive feelings
• abusive partner may be tolerated for long periods to avoid
disturbing sense of atttachment
• INTERVIEWS: appear compliant, try to cooperate, welcome
specific questions and look for guidance

FEATURES:
• preoccuppied with rules, regulations, neatness, details,
orderliness, and achievement of perfection
• lack flexibility and intolerant
• capable of prolonged work, provided it is routinized
• limited interpersonal skills
○ formal and lack sense of humor
○ alienate people around them
○ unable to compromise
○ insist others submit to their needs
○ eager to please those they see more powerful
○ indecisive and ruminate due to fear of mistakes
INTERVIEWS:
• stiff, formal, rigid demeanor
• constricted affect
• lack spontaneity, often mood is serious
• anxious about not being in control
• answers unusually detailed

DEFENSE MECHANISMS:
• rationalization
• isolation
• intellectualization
• reaction formation
• undoing

• CARDINAL FEATURE: impaired control of the expression of

emotions and impulses
• emotions are labile and shalllow
○ euphoria or apathy may be prominent
○ euphoria mimic hypomania, genuine elation is absent
○ hollow and silly ring to their excitement and facile
jocularity, frontal lobes involved
○ FRONTAL LOBE SYNDROME
▪ prominent indifference and apathy
▪ lack of concern for events in immediate envi.
▪ temper outbursts from alcohol ingestion, can lead
to violence
▪ expression of impulses
□ inappropriate jokes
□ coarse manner
□ improper sexual advances
□ antisocial conduct
▪ diminished foresight and cannot anticipate the
social and legal consequences
○ TEMPORAL LOBE EPILEPSY
▪ humorlessness
▪ hypergraphia
▪ hyperreligiosity
▪ marked aggressiveness during seizures

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 ○ TEMPORAL LOBE EPILEPSY
▪ humorlessness
▪ hypergraphia
▪ hyperreligiosity
▪ marked aggressiveness during seizures
• have a clear sensorium
• suspect diagnosis in patients who show marked changes in
behavior or personality involving emotional lability and
impaired impulse control
○ no history of mental d/o
○ personality cxs occur abruptly

ETIOLOGY
GENETIC FACTORS: TEMPERAMENT:
• monodizygotic > dizygotic • Refers to body's biases in the modulation of conditioned
• CLUSTER A PD behavioral responses to prescriptive physical stimuli
○ more common in biologic relatives of those with schizophrenia • behavioral conditioning (procedural learning)
○ SCHIZOTYPAL & SCHIZOPHRENIA: ○ presemantic sensations that elicit basic emotions
▪ increased prevalence of schizotypal features in families of schizophrenic independent of conscious recognition, descriptive
patients observation, reflection, reasoning
▪ mainly, not associated with comorbid affective symptoms • stylistic component of behavior (how)
○ less correlation between paranoid or schizoid PD and schizophrenia ○ differentiated from motivation (why) and content
• CLUSTER B PD (what)
○ + genetic basis • the 4 temperaments are closely associated with the 4 basic
○ antisocial PD assctd with alcohol use d/o emotions
○ depression & borderline PD ▪ harm avoidance & fear
○ have more relatives with mood d/o ▪ novelty seeking & anger
○ strong assoc. b/w histrionic PD and somatic symptom d/o ▪ reward dependence & attachment
▪ persistence & ambition
• CLUSTER C PD
○ individual differences in temperament and basic
○ + genetic basis
emotions modify the processing of sensory
○ avoidant PDs have high an
information and shape early learning characteristics
○ OC traits more common in monozygotic twins
• moderately heritable, observable in early childhood,
○ OCPD + depression
relatively stable in time, moderately predictive of adolescent
▪ shortened REM latency period
and adult behavior
▪ abnormal dexamethasone-suppression test (DST)
○ stabilize during the 2nd and 3rd years of life
○ temperament traits at ages 10 to 11 year, moderately
BIOLOGIC FACTORS: predictive of personality traits at ages 15, 18, 27
• HORMONES • the 4 dimensions are universal across different cultures,
○ impulsive traits show high levels of testosterone, 17-estradiol, ethnic groups, and political systems
estrone • HARM AVOIDANCE
○ DST are abnormal in some with borderline PD who also have ○ involves heritable bias in the inhibition of behavior in
depressive symptoms response to signals of punishment and frustrative non-
• PLATELET MONOAMINE OXIDASE reward
○ low platelet MAO levels spend more time in social activities than ○ HIGH harm avoidance is a fear of uncertainty, social
with high levels inhibition, shyness, passive avoidance of problems &
○ low platelet MAo levels in some schizotypal d/o danger, rapid fatigability, pessimistic worry
• SMOOTH PURSUIT EYE MOVEMENTS ○ LOW harm avoidance are carefree, courageous,
○ saccadic in introverted persons, low self-esteem, tend to withdraw energetic, ouotgoing, optimistic
and schizotypal PD ○ BZD disinhibit avoidance by GABA-ergic inhibition of
○ indicate role of inheritance serotonergic neurons from dorsal raphe nuclei
• NEUROTRANSMITTERS ○ patients given serotonin drugs show decreased harm
avoidance behavior
○ levels of 5-hydroxyindoleacetic acid (5-HIAA) - metabolite of
serotonin • NOVELTY SEEKING
▪ low in persons who attempt suicide, impulsive, aggressive ○ reflects a heritable bias in initiation or activation of

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 ○ indicate role of inheritance serotonergic neurons from dorsal raphe nuclei
• NEUROTRANSMITTERS ○ patients given serotonin drugs show decreased harm
avoidance behavior
○ levels of 5-hydroxyindoleacetic acid (5-HIAA) - metabolite of
serotonin • NOVELTY SEEKING
▪ low in persons who attempt suicide, impulsive, aggressive ○ reflects a heritable bias in initiation or activation of
○ raising serotonin levels with serotonergic agents (fluoxetine) appetitive approach in response to novelty, approach
▪ can produce dramatic changes in character traits personality to signals of reward, active avoidance of conditioned
▪ serotonin can reduce depression, impulsiveness, rumination, signals of punishment, and escape from unconditioned
produce sense of well-being punishment
○ increased dopamine concentrations in CNS can induce euphoria ○ it is an exploratory activity
○ HIGH novelty seeking are quick-tempered, curious,
• ELECTROPHYSIOLOGY
easily bored, impulsive, extravagant, disorderly
○ abnormalities in EEG mot common in antisocial & borderline types
○ LOW novelty seeking slow tempered, uninquiring,
▪ slow-wave activity
stoical, reflective, frugal, reserved, tolerant of
• OTHER
monotony, orderly
○ personality change due to another medical condition
○ dopaminergic projections have crucial role in novelty
▪ usual cause: structural brain damage seeking
○ cerebral neoplasms and vascular accidents ▪ involve increased reuptake of dopamine at
▪ particularly temporal & frontal presynaptic terminals
□ requiring frequent stimulation to maintain
PSYCHOANALYTIC FACTORS: optimal levels of postsynaptic
• Sigmund Freud: personality traits are related to fixation at one psychosexual dopaminergic stimulation
stage of development • REWARD DEPENDENCE
○ EXAMPLE: ORAL CHARACTER ○ reflects maintenance of behavior in response to cues
▪ dependence on others for food is prominent of social reward
▪ passive and dependent character ○ HIGH reward dependence are tender-hearted,
○ EXAMPLE: ANAL CHARACTER sensitive, dedicated, dependent, warmly sociable
▪ struggles over toilet training ○ LOW reward dependence are practical, tough-minded,
▪ stubborn, parsimonious, highly conscientious cold, socially insensitive, irresolute, indifferent if alone
• Wilhelm Reich: character armor ○ NORADRENERGIC projections from locus coereleus and
○ describe individuals' characteristic defensive styles for protecting SEROTONERGIC projections from median raphe
themselves from internal impulses and interpersonal anxiety in significant influence reward conditioning
relationships • PERSISTENCE
○ paranoid PD: projection ○ reflects maintenance of behavior despite frustration,
○ schizoid PD: withdrawal fatigue, intermittent reinforcement
○ when dfenses work effectively, perosns with PD master feelings of ○ manifests as industriousness, determination,
anxiety, depression, anger, guilt, other affects ambitiousness, perfectionism
▪ behavior is ego-syntonic: creates no distress for them ○ HIGHLY persistent, are hard-working, perseverant,
• internal object relations ambitious, overachievers who tend to intensify effort
○ through introjection, children internalize a parent or significant person in response to anticipated rewards
as an internal presence that continues on to feel like an object than a self ▪ view frustration and fatigue as personal
○ through identification, children internalize parents and others in such a challenges
way that they incorporate traits of external objects into the self, and child ○ LOW persistence are indolent, inactive, unstable,
owns the traits erratic, tend to give up easily when faced with
○ internal self-representations and object representations crucial in frustration, rarely strive for higher accomplishments
personality dev't ○ differences in persistence correlated with a circuit
▪ through externalization and projective identification, played out in involving the ventral striatum, orbitofrontal
interpersonal scenarios where they coerce others to play a role in cortex/rostral insula, dorsal anterior cingulate cortex
the patient's internal life

PARANOID PERSONALITY DISORDER SCHIZOID PERSONALITY DISORDER

EPIDEMIOLOGY: EPIDEMIOLOGY:
• 0.5 to 4.4 % of gen pop • prevalence 3.1 to 4.9% gen pop
• rarely seek tx themselves • more common in men
• relatives of patients with schizophrenia show higher incidence of paranoid PD • persons with d/o tend to gravitate toward solitary jobs involving little
• familial relationship with delusional disorder, persecutory type contact with others
• more common in men • prefer night work to not deal with many persons
• increased prevalence among relatives of those with schizophrenia or
DIFFERENTIAL DIAGNOSIS: schizotypal PD
• differentiated from delusional disorder by ABSENCE OF FIXED DELUSIONS
• lack hallucinations or formal thought d/o vs schizophrenia DIFFERENTIAL DIAGNOSIS:
• paranoid PD vs borderline PD • no positive psychotic symptoms, hallucinations & delusions in schizoid PD
○ paranoid patients are rarely capable of overly involved, tumultuous • paranoid vs schizoid
relationships ○ paranoid exhibit more social engagement, history of aggressive verbal
• lack long history of antisocial behaviors with antisocial character behavior, greater tendency to project feelings onto others
• schizoid PD are withdrawn, aloof, no paranoid ideation • OC and avoidant PDs experience loneliness as dysphoric, possess a more
abundant hx of past object relations, do not engage much in autistic reverie
COMORBIDITY: • schizoid vs schizotypal
• increased risk for major depression, OCD, agoraphobia, substance use d/o ○ schizotypal is more similar to schizophrenia in oddities of perception,
• MOST COMMON CO-OCCURRING PD: thought, behavior, communication
○ schizotypal • avoidant PD tend to isolate but wish to participate vs schizoid who do not
○ schizoid want to participate
○ narcissistic
○ avoidant COMORBIDITY:
○ borderline • premorbid antecedent of delusional d/o, schizophrenia,
• may be a premorbid antecedent of delusional d/o, persecutory type rarely major depression
• MOST COMMON CO-OCCURRING PDs:
COURSE & PROGNOSIS: ○ paranoid
○ schizotypal
• some, PD is lifelong while to some it's a harbinger of schizophrenia
• paranoid traits give way to reaction formation, appropriate concern with morality, ○ avoidant
altruistic concerns as they mature
• occupational and marital problems are common
COURSE & PROGNOSIS:
• onset occurs in early childhood or adolescence
• complications: brief reactive psychosis
• long-lasting but not lifelong
• severe problems in social relations
TREATMENT APPROACH: •
•
occupational problems when interpersonal involvement required
solitary work favourable
• PSYCHOTHERAPY

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 • onset occurs in early childhood or adolescence
• complications: brief reactive psychosis
• long-lasting but not lifelong
• severe problems in social relations
TREATMENT APPROACH: •
•
occupational problems when interpersonal involvement required
solitary work favourable
• PSYCHOTHERAPY
• complications: brief reactive psychosis, in response to stress
○ treatment of choice
○ therapists should be straightforward TREATMENT APPROACH:
○ trust and tolerance of intimacy are troubled areas for patient
• PSYCHOTHERAPY
○ overzealous use of interpretation increases patient's mistrust
○ TX similar to paranoid PD
○ they do not do well in group psychotherapy and cannot tolerate the
○ patients tend to ward introspection
intrusiveness of behavior therapy
○ as trust develops, they may reveal a plethora of fantasies, imaginary
○ therapists should never offer to take control unless they are willing to do so
friends, fears of unbearable dependence
• PHARMACOTHERAPY ○ in group therapy, they may be silent for long periods, but become
○ little evidence involved nevertheless
○ low dose novel antipsychotics for psychotic symptoms ○ should be protected against aggressive attack from group members
○ anticonvulsant for irritability for their proclivity to be silent
○ with time, the group becomes important to the schizoid
• PHARMACOTHERAPY
○ use of psychotropics to target social and emotional detachment

SCHIZOTYPAL PD
EPIDEMIOLOGY:
• 3.9 to 4.6 % pop
• frequent in females with fragile X syndrome
• higher assoc among biologic relatives of schizophrenia
• mono > dizy

DIFFERENTIAL DIAGNOSIS:
• VS SCHIZOID AND AVOIDANT, SCHIZOTYPAL + oddities in behavior, thinking,
perception, communication
• autism have more severely impaired social interactions and restricted behaviors
and interests than those with schizotypal
• schizotypal, absence of psychosis vs schizophrenia
○ if psychotic symptoms appear, it is brief & fragmentary
• paranoid PD is suspicious but lack oddities in behavior of schizotypal

COMORBIDITY:
• > 1/2 have at least 1 episode of major depression
• 30-50% have major depression
• MOST COMMON CO-OCCURRING PD:
○ schizoid
○ paranoid
○ avoidant
○ borderline

COURSE & PROGNOSIS:

• premorbid personality of those with schizophrenia
• can maintain a stable schizotypal personality, marry & work
• complications: transient psychotic episodes, in response to stress
• symptoms can become significant to meet criteria for schizophreniform d/o,
delusional d/o, brief psychotic d/o

TREATMENT APPROACH:
• PSYCHOTHERAPY
○ clinicians must deal sensitively, avoid ridiculing or judging patients' odd beliefs
• PHARMACOTHERAPY
○ antipsychotic meds for ideas of reference, illusions
○ antidepressants when depressive component present

ANTISOCIAL PD BORDERLINE PD
EPIDEMIOLOGY: EPIDEMIOLOGY:
• Prevalence 3% for males, 1% females gen pop • 2% gen pop
• frequent among first degree relatives of individuals with this PD • more common in women than men
○ biologic relatives of females have an increased risk vs male biologic relatives • more common in younger indivs
○ + familial transmission of antisocial PD, substance use and somatic symptom d/o ○ suggesting natural tendency toward maturation and remission
▪ antisocial PD: characteristic of females • common childhood histories:
▪ substance use and somatic symp d/o: characteristic of males ○ physical & sexual abuse, neglect, hostile conduct, early parental
○ conduct d/o ( before age 10y/o) and accompanying ADHD increases likelihood of loss or separation
developing antisocial PD in adult life • borderline PD 5x more common among relatives of indivs with same d/o
○ conduct d/o more likely to develop into antisocial PD with erratic parenting, • increased prevalence of mood d/o, antisocial PD, substance use d/o is
neglect, or inconsistent parental discipline. common in 1st degree relatives of persons with borderline PD

DIFFERENTIAL DIAGNOSIS: DIFFERENTIAL DIAGNOSIS:

• differs from mere illegal behavior = involves many areas of person's life • different from mood d/o; not typically present:
• CRIMINAL BEHAVIOR not associated with a PD: ○ fear of abandonment
○ when illegal behavior is only for gain and does not include rigid, maladaptive, persistent ○ highly unpredictable behavior
personality traits ○ tumultuous interpersonal relationships
• ANTISOCIAL PD & SUBSTANCE USE D/O ○ seeing others as all good or all bad
○ when both begin in childhood and continue into adult life, we DIAGNOSE BOTH D/Os ○ complaints of being numb, empty
○ when antisocial behavior is SECONDARY to premorbid alcohol use d/o or another substance ○ lack consistent sense of identity
d/o, diagnosis of antisocial PD is not warranted • different from identity problems
• IN DIAGNOSING ANTISOCIAL PD ○ limited to a developmental stage
○ clinicians must adjust for the distorting effects of SES, cultural background, and sex • borderline PD lacks prolonged psychotic episodes, thought d/o, and other

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 ○ when both begin in childhood and continue into adult life, we DIAGNOSE BOTH D/Os ○ complaints of being numb, empty
○ when antisocial behavior is SECONDARY to premorbid alcohol use d/o or another substance ○ lack consistent sense of identity
d/o, diagnosis of antisocial PD is not warranted • different from identity problems
• IN DIAGNOSING ANTISOCIAL PD ○ limited to a developmental stage
○ clinicians must adjust for the distorting effects of SES, cultural background, and sex • borderline PD lacks prolonged psychotic episodes, thought d/o, and other
○ diagnosis of antisocial PD is not warranted when intellectual disability, schizophrenia, mania classic schizophrenic signs
can explain the symptoms ○ short-lived psychotic episodes only
• narcissistic, histrionic, paranoid: can be differentiated from antisocial PD;
○ rarely include serious criminality and aggressiveness COMORBIDITY:
• borderline PD, sometimes assoc with criminality • increased risk for major depression, substance use d/o, eating d/o (notabbly
○ individuals with borderline personality who commit crimes tend to display high novelty bulimia), PTSD, ADHD, somatic symptom d/o
seeking & high harm avoidance behaviors
○ individuals with antisocial personality tend to display high novelty seeking & low harm
avoidance behaviors
COURSE & PROGNOSIS:
• most commonly follows pattern of chronic instability in early adulthood +
COMORBIDITY: episodes of severe affective and impulsive dyscontrol
• impairment and risk for suicide highest in young adult years and wane with
• increased risk for impulse control d/o, major depression, substance use d/o, pathologic gambling, advancing age
anxiety d/o, somatic symptom d/o • 4th & 5th decades, attain greater stability in relationships and functioning
• MOST COMMON CO-OCCURRING PD: ○ impairment: frequent job losses, interrupted education, broken
○ narcissistic marriages
○ borderline • complications: psychotic like symptoms in response to stress, premature
○ histrionic death or physicala handicaps from suicide
○ suicidal gestures, failed suicide, self-injurious behavior
COURSE & PROGNOSIS:
• runs an unremitting course, height of antisocial behavior in late adolescence
• some reports say symptoms decrease as person ages TREATMENT APPROACH:
○ even after BURN OUT, usually continue to be irritable, impulsive, detached • PSYCHOTHERAPY
• complications: dysphoria, tension, low tolerance for boredom, depressed mood, premature, ○ treatment of choice
violent death ○ most successful in combination with pharmacotherapy
○ patients regress quickly, act out impulses, show labile or fixed negative
TREATMENT APPROACH: or positive transferences
• PSYCHOTHERAPY ○ projective identification may cause countertransference problems
○ limited evidence to the use of psychotherapeutic approaches ○ splitting defense mechanism causes patients to love and hate therapists
○ respond better to contingency management and other reward-based interventions than and others
they do CBT ○ a REALITY-ORIENTED approach is more effective than IN-DEPTH
• PHARMACOTHERAPY interpretations of the unconscious
○ can deal with incapacitating symptoms such as anxiety, rage, depression ○ behavior therapy can help manage impulses & angry outbursts, reduce
sensitivity to criticism and rejection
○ use meds judiciously since they can misuse substances
○ social skills training with video playback help improve interpersonal
○ anticonvulsants for aggressive behaviors, especially with abnormal waveforms on EEG
behavior
▪ B-adrenergic receptor antagonists, lithium, antipsychotics also reduce aggression
○ they do well in a hospital setting where they receive intensive
psychotherapy on both individual and group basis
HISTRIONIC PD ▪ remain in hospital until show marked improvement, up to 1 year
in some
EPIDEMIOLOGY • DIALECTICAL BEHAVIOR THERAPY
• 2% gen pop ○ eclectic, drawing on concepts derived from supportive, cognitive, and
• equally frequent men and women behavioral therapies
• tend to run in families ○ 4 PRIMARY MODES:
• genetic link b/w histrionic and antisocial PD and alcohol use d/o ▪ group skill training
▪ individual therapy
DIFFERENTIAL DIAGNOSIS ▪ phone consultation
• distinguishing between histrionic and borderline PD is challenging ▪ consultation team
○ but in borderline, suicide attempts, identity diffusion, brief psychotic episodes more likely ○ patients seen weekly
• somatic symptom d/o may occur in conjunction with histrionic PD, should diagnose both • MENTALIZATION-BASED TREATMENT
• patients with brief psychotic d/o & dissociative d/o may warrant coex diagnosis of histrionic PD ○ a social construct that allows person to be attentive to the mental states
of oneself and of others
COMORIDITY
▪ comes from person's awareness of mental processes and
• increased risk for major depression, somatic symptom d/o, conversion d/o
subjective states arising in interpersonal interactions
• MOST COMMON CO-OCCURRING PD:
○ based on theory that BPD symptoms are a result of patient's reduced
○ narcissistic
capacities to mentalize
○ borderline
• TRANSFERENCE-FOCUSED PSYCHOTHERAPY
○ antisocial
○ grounded in object relations theory
○ dependent
○ relies on 2 major processes
▪ (1) CLARIFICATION
COURSE & PROGNOSIS
□ transference is analyzed more directly than in traditional
• with age, show fewer symptoms
psychotherapy
• sensation seekers, get in trouble with law, abuse substances, act promiscuously
□ patient becomes quickly aware of his distortions about the
• complications: frequent suicidal gestures and threats to coerce better caregiving, unstable
therapist
interpersonal relations, shallow, ungratifying, frequent marital problems secondary to neglect
▪ (2) CONFRONTATION
long-term relations
□ therapist points out how these transferential distortions
TREATMENT APPROACH interfere with interpersonal relations
• PSYCHOTHERAPY ○ if therapy successful, need for splitting diminishes, object relations
○ often unaware of their real feelings improved, achieve normal level functioning
▪ clarification of inner feelings is necessary • PHARMACOTHERAPY
○ TREATMENT OF CHOICE ○ antipsychotics help control anger, hostility, brief psychotic episodes
▪ psychoanalytically oriented psychotherapy ○ antidepressants improve depressed mood
• PHARMACOTHERAPY ▪ benzodiazepines avoided due to risk of abuse and patients
○ antidepressants for depression and somatic complaints become disinhibited
○ anti anxiety for anxiety ○ anticonvulsants improve functioning (carbamazepine)
○ antipsychotics for derealization and illusions ○ serotonergic agents also helpful (SSRIs)

NARCISSISTIC PD AVOIDANT PD
EPIDEMIOLOGY EPIDEMIOLOGY
• <1% gen pop • 0.5 to 2% gen pop
• 2 to 16% clinical pop • occurs equally in men and women
• more common in men
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS • complicated to distinguish from social anxiety d/o
• borderline, histrionic and antisocial often accompany narcissistic PD ○ SAD, specific situations, rather than interpersonal contact in general,

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 • <1% gen pop • 0.5 to 2% gen pop
• 2 to 16% clinical pop • occurs equally in men and women
• more common in men
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS • complicated to distinguish from social anxiety d/o
• borderline, histrionic and antisocial often accompany narcissistic PD ○ SAD, specific situations, rather than interpersonal contact in general,
• narci have less anxiety than borderline, less chaotic and less likely to attempt suicide are avoided
○ antisocial: history of impulsive behavior, often assoc with alcohol & other substances and ○ can co-occur
gets in trouble with the law • panic d/o with agoraphobia also manifest avoidance, but after onset of
○ histrionic: features of exhibitionism and interpersonal manipulativeness resembling panic attacks
narcissistic • APD desire social interaction, unlike schizoid who wants to be alone
○ narcissistic PD distinguished from the grandiosity of mania by the episodic course, assctd • APD are not as demanding, irritable or unpredictable as those with
euphoria, functional impairment in a manic or hypomanic episode borderline and histrionic
• avoidant and dependent are similar
COMORBIDITY • DPD have greater fear of being abandoned or unloved
• Increased risk for major depression and substance use d/o (cocaine use)
• MOST COMMON CO-OCCURRING PD: COMORBIDITY
○ borderline • increased risk for mood and anxiety d/o (SAD)
○ antisocial • MOST COMMON CO-OCCURRING PD:
○ histrionic ○ schizotypal
○ paranoid ○ schizoid
○ paranoid
COURSE & PROGNOSIS ○ dependent
• chronic & difficult to treat ○ borderline
• handle aging poorly
○ more vulnerable to mid life crises COURSE & PROGNOSIS
• symptoms tend to diminish after age 40, pessimism usually develops • begins in childhood with shyness and fear of strangers and new situations
• impairment: marital problems & interpersonal relationships • can function in a protected environment
• complications: social withdrawal, depressed mood, dysthymic or major depressive d/o in reax to • some marry, have children, live their lives surrounded by family members
criticism or failure • if support system fails, subject to depression, anxiety, anger
• phobic avoidance is common
TREATMENT APPROACH ○ histories of social anxiety d/o
• PSYCHOTHERAPY
○ patients must renounce their narcissism to make progress TREATMENT APPROACH
○ clinicians advocate group therapy and develop empathic response to others • PSYCHOTHERAPY
• PHARMACOTHERAPY ○ depends on solidifying an alliance with patients
○ lithium when clinical picture includes mood swings ○ as trust develops, therapist must convey an accepting attitude
○ antidepressants (serotonergic): to tolerate rejection and for depression toward patient fears, esp fear of rejection
○ eventually encouraged to move out into the world
○ group therapy can help understand how their sensitivity affect
them and others
○ assertive training to express needs openly and enlarge self-
esteem
• PHARMACOTHERAPY
○ manage anxiety an depression
○ B-adrenergic receptor antagonists (atenolol), manage ANS
hyperactivity
○ serotonergic agents for rejection sensitivity
○ THEO: dopaminergic drugs might engender novelty-seeking
behavior

DEPENDENT PD OBSESSIVE-COMPULSIVE PD
EPIDEMIOLOGY EPIDEMIOLOGY
• equally common in men and women • 2 to 8 % gen pop
• 0.5 to 0.6% prevalence • men>women
• persons with chronic physical illness in childhood or separation anxiety d/o: most susceptible to
DPD
DIFFERENTIAL DIAGNOSIS
• A personality d/o diagnosis is reserved for those with significant
DIFFERENTIAL DIAGNOSIS impairments in their occupational or social effectiveness
• DEPENDENCE is a prominent factor in histrionic and borderline PD • in some cases, delusional d/o coexists with PDs, diagnose both
○ DPD have long-term relationship with 1 person than a series of persons, and they're not
overly manipulative COMORBIDITY
• dependent behavior also seen in agoraphobia, panic d/o, depressive d/o • Increased risk for major depression and anxiety d/o
○ but, tend to have high level overt anxiety, panic, depression COURSE & PROGNOSIS
COMORBIDITY • occupational and social difficulties are typical
• increased risk for major depression, anxiety d/o, adjustment d/o • harbinger of schizophrenia or for major depressive d/o
• somatic symptom d/o as comorbidity • flourish in positions demanding methodical, deductive, detailed
• MOST COMMONLY OCCURRING PD: work but vulnerable to unexpected changes
○ histrionic • depressive d/o's of late onset are common
○ avoidant • complications: distress when confronted with new situations
○ borderline requiring flexibility and compromise
COURSE & PROGNOSIS ○ MI secondary to features of Type A personalities ( time
• occupational functioning tends to be impaired since they cannot act independently and w/o close urgency, hostility and competitiveness)
supervision
○ social relationships limited to those who they can depend, many suffer physical and mental TREATMENT APPROACH
abuse because they can't assert themselves • PSYCHOTHERAPY
• risk major depressive d/o if they lose person they depend on ○ often aware of their suffering and seek tx
• complications: low SES, inadequate family and marital functioning, mood d/o, anxiety d/o, ○ CBT, individual or group
adjustment d/o, SAD ○ interpersonal psychotherapy may improve depressive
symptoms
TREATMENT APPROACH • PHARMACOTHERAPY
• PSYCHOTHERAPY ○ fluvoxamine and carbamazepine and citalopram
○ treatment often successful (comorbid depression)
○ insight-oriented therapies enable to understand antecedents of behavior ○ citalopram said to perform better than sertraline in
▪ behavioral therapy, assertiveness training, family therapy, group therapy reducing number of OCPD traits
○ pitfall: when therapist encourages patient to change dynamics of pathologic relationship
▪ patient becomes anxious and unable to coop in therapy
▪ torn b/w complying with therapist and losing external pathologic relationship
□ always show respect to patient's feelings of attachment no matter how
pathologic they seem

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 pathologic they seem
• PHARMACOTHERAPY
○ deal with anxiety and depression
○ antidepressants for those who experience panic attacks or high levels of separation anxiety

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