PERSONALITY DISORDERS Personality  observable behavior AND subjective inner experience (public & private aspects)  passive/ aggressive  ambitious

, religious, friendly  qualifications of a personality d/o implies certain predictions about how a person will behave under certain circumstances.  Px are more likely to refuse help & deny problems  Symptoms are  Alloplastic  able to adapt to & alter external environment  Ego syntonic  acceptable to the ego  Px do NOT feel anxiety about their maladaptive behavior DSM IV TR definition:  Enduring subjective experiences & behavior that deviate from cultural standards (of the individual)  2 or more of:  Cognition  ways of percieving & interpreting self, other people & events  Affectivity  range, intensity, lability, & appropriateness of emotional response  Interpersonal functioning  Impulse control  Rigidly (inflexible) pervasive & maladaptive  Adolescent/ early adulthood onset  Stable  Lead to unhappiness & impairment (produce fxnal impairment or subjective distress)  Not a direct cause of another mental d/o or substance (medication/drugs)  Cluster A  px percieve as odd & eccentric  Paranoid  Schizoid  Schizotypal  Cluster B  dramatic, emotional & erratic  antisocial  borderline  histrionic  narcissistic  Cluster C  anxious, fearful  Avoidant  Dependent  Obsessive compulsive  Not otherwise specified  Passive aggressive  Depressive  Etiology  Cluster A – occur more commonly in biological relatives of px w/ schizophrenia (esp schizotypal); there is less correlation between paranoid or schizoid personality d/o to schizophrenia  Cluster B – have more relatives with mood disorders; have overlap symptoms  Antisocial  alcohol  Borderline  depression (also have abn DST)  Histrionic  somatization (Briquet’s)  Cluster C –  Avoidant  anxiety  OC  monozygotic; depresion (short REM & abn dexamethasone suppression tests : DST )

Biological factors  Impulsive traits   testosterone, 17 estradiol, estrone   MAO  schizotypal & more social  smooth pursuit eye movements  saccadic (jumpy) in px who are introverted,  self esteem, withdrawn & schizotypal  endorphins  ~morphine, analgesia, suppresion of arousal   endorphins  phlegmatic persons   5HIAA (serotonin metabolite)  suicidal, impulsive, aggressive   5HT (using Prozac)   depression, impulsiveness, rumination & produce sense of well being   dopamine (using psychostimulants like amphetamine)  induces euphoria  EEG changes  antisocial & borderline (slow wave) Psychoanalytic factors  Freud  Fixation at one psychosexual stage of dvlpt  Oral character  passive & dependent (dependence on others for food)  Anal character  subborn, parsimonious, & highly conscientious (struggle over toilet training)   Reich Character armor  person’s defensive style to protect themselves from internal mpulses & interpersonal anxiety  Paranoid  uses projection  Schizoid  associated with withdrawal  When the defenses work, the px master their feelings therefore viewing their behavior as ego syntonic (creating no distress to them even if it adversely affects others) Internal object relations  Introjection  children internalize a parent or another significant person as an internal presence that continues to feel like an object rather than a self  Child owns the traits of the external object Defense mechanisms  4 lodestars of inner life (instinct (wish/need), reality, important persons, conscience)  Fantasy  px schizoid, labeled as eccentric, lonely or frightened, seek solace & satisfaction within themselves by creating imaginary lives/friends; fear of intimacy  Dissociation / Denial  polyanna like replacement of unpleasant affects w/ pleasant ones  Isolation  orderly, controlled persons who are often labeled OC  Projection  px attribute their own unacknowledged feelings to others; excessive faultfinding & sensitivity to criticism  Splitting  good and bad  Passive aggression  turn their anger against themselves (masochism)  Acting out  tantrums, child abuse, pleasureless promiscuity  Projective identificaton  @ borderline personality

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 undistressed M > F, NO familial pattern & appear

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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

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

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ScHiZOiD personality d/o  Lifelong pattern of social withdrawal  Discomfort with human interaction, introverted w/ bland constricted affect  Eccentric, isolated or lonely 

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 


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

AnTiSoCiaL personality d/o  Inability to conform to the social norms  NOT synonymous w/ criminality  3% M > 1% F   poor urban areas & mobile residents  boys from large families  onset before 15 (boys earlier)  in prison, 75%  familial pattern, 5% more comon in 1st degree relatives  Mask of sanity  Hervey Cleckley  Px may appear composed & credible, but beneath the veneer there is tension, hostility, irritability & rage  Stress interview (confrontation) may be necessary DSM IV TR Pervasive pattern of dsregard for and violation of rights of others occuring since age 15 years 3 or more of..  failure to conform to social norms w/ respect to lawful behaviors (repeatedly performing acts that are grounds for arrest)  deceitfulness, (repeated lying, use of aliases, or conning others for personal profit or pleasure)  impulsivity or failure to plan ahead  irritability and aggressiveness, (repeated physical fights or assaults)  reckless disregard for safety of self or others  consistent irresponsibility (repeated failure to sustain consistent work behavior or honor financial obligations)  lack of remorse (indifference to having hurt, mistreated, or stolen from another) at least 18 y/o evidence of conduct d/o w/ onset before age 15 y/o not during schizophrenia or manic episode

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DSM IV TR Pervasive pattern of instability of interpersonal relationships, self image, and affets & marked impulsivity  Early adulthood  5 or more of..  frantic efforts to avoid real or imagined abandonment  unstable & intense interpersonal relationships characterized by alternating between extremes of idealization & devaluation  identity disturbance: markedly & persistently unstable self image or sense of self  impulsivity in at least 2 areas that are potentially self damaging  spending, sex, subst abuse, reckless driving, binge eating  recurrent suicidal behavior, gestures, or threats or self mutilating behavior  affective instability due to a marked reactiviyt of mood  intense episodic dysphoria, irritability, anxiety  lasting few hrs only  chronic feelings of emptiness  inappropriate intense anger or difficulty controlling anger  frequent displays of temper, constant anger, recurrent physical fights  transient, stress related paranoid ideation or severe dissociative symptoms  

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unremitting course --> reaches peak at late adolescence  have somatization disorders, depression, alcohol use, substance abuse  Tx  Psychotherapy --> except immobilized px  When px are among peers, their lack of motivation for change disappears  Pharmacotherapy  Psychostimulants  Methylphenidate --> attention deficit/hyperactivty d/o  Antiepileptic drugs --> control impulsive behavior  Carbamazepine  Valproate   adrenergic antagonist -->  aggresion BoRdErLiNe personality d/o  on the border between neurosis & psychosis  ambulatory schizophrenia  as-if personality d/o (by Deutsch)  pseudoneurotic schizophrenia (by Hoch & Politan)  psychotic character d/o (by Frosch)  emotionally unstable personality d/o (ICD10)  1-2% gen pop  F (2x) > M   prevalence of MDD, alcohol use, subst abuse 

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shortened REM latency, sleep continuity disturbance, abnormal DST, abn thyrotropin releasing hormone results  also seen in depressive d/o appear in a state of crisis mood swings common short lived psychotic symptoms (micropsychotic episodes) --> difference from schizophrenia cannot tolerate being alone lack of consistent sense of identity (identity diffusion) projective identification  Otto Kernberg  Defense mechanism  Intolerable aspect of the self are projected onto another; the other person is induced to play the projected role & the two persons act in unison Rorschach test --> unstructured projective test which shows the deviant processes Distortion of relationships by considering a person as either all good or all bad.

fairly stable no progression towards schizophrenia, but  incidence of MDD  Dx before age 40 (when many life cycle choices are made)  Tx  Psychotherapy  For best results add pharmacotherapy  Dialectical behavior therapy  Esp those w/ parasuicidal behavior (freq cutting)  Pharmacotherapy  Antipsychotics – control anger, hostility, & brief psychotic episodes  Antidepressants –  MAOI – modulate impulsive behavior  Benzodiazepines –  Alprazolam – help anxiety & depression (caution: disinhibition)  Anticonvulsants  Carbamazepine – improve global fxning  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   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

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)  preoccupied w/ fantasies of unlimited success, 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

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

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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

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 (unable to complete a project because his/her own overly 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  

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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 

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

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