Personality disorders

Presenter- Dr Bishruta Goswami Moderator- Dr Soumitra Ghosh

PGT, Dept of psychiatry Professor and Head, Dept pf Psychiatry
Tezpur Medical college and Hospital Tezpur Medical College and Hospital
Plan of presentation-

▪ Introduction
▪ History
▪ Etiology
▪ Classification
▪ Treatment
▪ Conclusion
▪ Bibliography
Introduction-
• Personality refers to all of the characteristics that adapt in unique ways to ever
changing internal and external environments.
• “A person is not a machine like objects that lacks self awareness.
C . Robert. Cloninger
• Personality disorder-Common and chronic.
• Prevalence- 10-20 % in general population
• Seen in almost 50% of Psychiatric illnesses and also a predisposing factor for
other psychiatric illness.
• Most likely to refuse psychiatric help.
Personality:- “Dynamic organization within the individuals of those psychophysical
systems that determine his or her unique adjustment to the environment” –
Gordon Allport

Dynamic Psychophysical Determinative

system
Definition

• (According to DSM 5) Personality disorder-

• An enduring pattern of behaviour and inner experience- that deviates significantly from the
indivisual’s cultural standards.
• Rigidly pervasive
• Onset-adolescent and early adulthood
• Stable through time cognition
• Leads to unhappiness and impairment affectivity
• Manifesting in at least 2 of the following 4 areas- interpersonal function
impulse control
Temperament: Character: Disorder:

Stylistic component The social and cultural A Syndrome with a

(how) of behavior contributions to personality given course

*harm avoidance
Novelty seeking
Reward dependence
persistence.

(high to low-different variants)

 History-
• Hippocrates- 4 humor

• James Prichard’s - “Moral Insanity”

• Eugen Kahn - “Psychopathy”

• Koch’s - Psychopathic inferiority in 1891

• Pierre Janet (1901) and Freud/Breuer - psychological traits associated with hysteria

• Object relation theorists emphasized the role of early interpersonal interaction.

( Dependent traits parental deprivation, OC control struggle with parental figures etc)
• Carl Gustav Jung : Shifted the focus from archaic stereotypical forms to modern
dimensional typologies

• Ernst Kretschmer :Typologies based on biological speculation

Athletic
Asthenic
Dysplastic
Pyknic

• Sheldon :
Endomorphic
Mesomorphic
Ectomorphic
• 1920s Kraepelin -spectrum concept

Personality types are biogenetically related variants of the paranoid

and affective psychosis.
These are forerunners of current
Paranoid,
Schizotypal,
Cyclothymic and
Depressive Traits
• Schneider (1923) – considered PDs as socially deviant extreme
variant of normally occurring personality.
*psychopathic
 Models of personality-
• Eysenck’s three basic types of personality :
A) extraversion – introversion.
B) neuroticism.
C) psychoticism.

• Psychodynamic approach – Freud

-personality structure consists of (Id. Ego and Super ego)
Cloninger 5 factor model- Openness to experience
Conscientiousness
Agreeableness
Extraversion
Neuroticism
Dimensions and categories…

Categorical model – used in DSM 5 and ICD 10

based on presenting symptoms (absent to severe)

Dimensional models
• Traits -basic elements of personality
• Traits -distributed along dimensions
• The structure of personality is common to all individuals ; but differs in different
combination of traits.
•Each person’s personality described in range of dimension.
•This influence the radical change to the classification of personality disorder in ICD 11.
classification
ICD 10 Classification-
• Paranoid personality disorder
• Schizoid personality disorder
• Dissocial PD
• Emotionally unstable PD
• Histrionic PD
• Anankastic PD
• Anxious PD
• Dependent PD
• Other specific PD
• PD , unspecified.
DSM 5 Classification-

Category A- Paranoid
schizoid
schizotypal Category C- Avoidant
Dependent
Obsessive-Compulsive Personality disorder

Category B- Antisocial
Borderline
Histrionic
Narcissistic
ICD 11- 6D10 (Block 1)
Personality disorders
Personality disorders are characterized by problem in functioning of aspects of the self
and/or interpersonal dysfunction.

▪Duration-2 years or more

▪Disturbance in cognition, emotional experience and emotional expression, behaviour
▪In personal and social situation.
Mild -6D10.0
Modearate-6D10.1
Severe-6D10.2
Severity unspecified-6D10.Z
ICD 11- 6D11
Prominent personality traits or patterns
Trait domain qualifiers
• Continuous with normal personality characteristics of the indivisual personality
• Not diagnostic
• Represent a set of dimension
• Describe personality functioning

▪Negative affectivity
▪Detachment
▪Dissociality
▪Disinhibition
▪Anankastia
▪Borderline pattern
Epidemiology :
▪ An estimated 10-20 % of individuals in the community have a personality disorder

▪ (Men= Women. Although ,sex difference present in terms of the specific type of
disorders.

▪ Urban > Rural.

▪ The prevalence of any personality disorder was found significantly lower in LMICs
than in HICs.
INDIAN SCENERIO :
Prevalence:0.3-1.6%
Male > Female
Observed rates in special populations :
University students :- 19.1%
Criminals :- 7.3-33.3 %
Substance use disorders :- 20- 55 %
Attempted suicide :- 47.8-62.2%
In the International Pilot Study Of Personality Disorders:
Schizotypal (19.1%), Borderline (14.7%) and emotionally unstable (8.6%)
In younger group : Emotionally unstable personality disorder > anankastic personality disorder ;while vice
versa in older group.
Etiology
▪ Genetic factors

▪ Biological factors

▪ Psychological factors
1. Genetic-
Twin study- common among mono-zygotic twins
Cluster A – common in biological relatives of patients with Schizophrenia.
-schizotypal personality disorder being the most common.

Cluster B - Anti-social - most commonly in the background of substance use disorder.

Depression is common – family background of patients with Borderline personality
Histrionic and somatization disorder
Cluster C- Obsessive compulsive traits - more common in MZ twins; showing some signs of
depression
avoidant personality disorders- increased anxiety levels.
Biological factors-

1. Hormones- (Testosterone , 17 estradiol ,estrone , DST)

2. Platelet Monoamine Oxidase
3. Smooth Pursuit Eye movement(saccadic-introvert, low self esteem ,schizotypal)
4. Neurotransmitters (Endogenous endorphin , Dopamine , Serotonin)
5. Electrophysiology – slow wave activity in Borderline and antisocial personality.
Psychological factors-

• Sigmund Freud- personality traits are related to fixation at one psychological stage of
development.
• Wilhelm Reich – Character armor

person’s characteristic defensive style foe protecting themselves from internal

impulses and from interpersonal anxiety in significant relationship.(ex- paranoid PD uses
projection)

• Internal Object Relationship. ( Identification – introjection and projective identification-

externalization)

• Common Defense mechanisms in PD - Fantasy , dissociation, Isolation , Projection , splitting .

Passive aggression , Acting out , Projective identification.
Cluster A personality

Odd , eccentric and

Aloof
Paranoid personality disorder-
▪Long standing suspiciousness and mistrust

▪Hostile , irritable and angry

▪Refuse responsibilities fort heir own feelings

▪Prevalence- 2-4 %

▪More common in relatives of Schizophrenia , with Schizophrenia

▪male > female

▪Minority groups , immigrants , deaf people – risk factors

Diagnostic criteria- DSM 5

Course-
▪ Mostly life long,
▪ Sometimes gives away Reaction
formation, appropriate concern
with mortality and altruism.
▪ Associated with occupational and
marital outcome
Schizoid personality disorder-
▪Cold and aloof, display a remote reserve and show no involvement with everyday events and the
concerns of others.
▪Quiet, distant, seclusive and unsociable.
▪Solitary interests and success at noncompetitive, lonely jobs that others find difficult to tolerate.
▪Their sexual lives may exist exclusively in fantasy, and they may postpone mature sexuality
indefinitely.
▪Usually reveal a lifelong inability to express anger directly
▪Self- absorbed and lost in daydreams, may have a normal capacity to recognize reality
Diagnostic criteria-

• Life history reflects solitary interest

and success at non-competitive,

solitary job that other finds

difficult to tolerate.

• course is usually life long.

• Patients who incur schizophrenia

are not known

 Schizotypal personality disorder-
• ICD-10 : Includes it among the psychotic disorders.
➢ Exhibit disturbed thinking & communicating.
➢ Speech maybe distinctive and peculiar, may have meaning only to them, and often needs interpretation.
➢ May not know their own feelings
➢ May be superstitious or claim powers of clairvoyance and believe they have special powers of though
and insight
➢ inner world maybe filled with vivid imaginary relationships and child-like fears and fantasies.
➢ They may admit to perceptual illusions or macropsia and confess that other persons seem wooden and al
the same.
➢ Poor interpersonal relationships ,have few, if any, friends
➢ severe cases -exhibit anhedonia and severe depression
▪ Under stress-may decompensate and
have brief psychotic symptoms.
▪ Sometimes in severe cases- Depression
and anhedonia.

▪ Current clinical thinking – it is the

premorbid personality of
Schizophrenia.
Cluster B-Dramatic, impulsive and erratic features
Antisocial personality disorder
▪ Pattern of socially irresponsible, exploitative, and guilt-ness behavior
▪ reflects a disregard for the rights of others.
▪ The ICD-10 -dissocial personality disorder.

Clinical features
▪ Lying, truancy, running away from home, thefts, fights, substance abuse, and illegal activities
▪ Often impress opposite-sex clinicians with the colorful, seductive aspects of their personalities
▪ Exhibit no anxiety and depression, a lack that may seem grossly incongruous with their situations
▪ heightened sense of reality testing impressing observers as having good verbal intelligence.
▪ so-called con men - extremely manipulative
▪ Promiscuity, spousal abuse, child abuse, and drunk driving are common events in their lives, they
appear to lack a conscience
Diagnostic criteria-

Course :
▪ Once develops, it runs an unremitting
course,
▪ usually occurring in late adolescence.
▪ The prognosis varies.
▪ Some reports indicate that symptoms
decrease as person grow older.
▪ Many with somatization disorder and
multiple physical complaints.
▪ Depressive disorder, alcohol use disorder
and other substance abuse are common.
Borderline personality disorder
• border between neurosis and psychosis
• extraordinarily unstable affect, mood, behavior, object relations and self- image.
• ambulatory schizophrenia, as-if personality, pseudo-neurotic schizophrenia and psychotic
character disorder.
Clinical features

• Always - state of crisis. Mood swings are common

• Argumentative at one moment depressed the next complain of having no feelings.
• Micro psychotic episodes .
• Highly unpredictable behaviour & achievements -rarely at the level of their abilities.
• Tumultuous interpersonal relationships - Cannot tolerate being alone.
Course-
• More common in females
• Prevalence- 1.6-5.9 %
• fairly stable, patient change little
over time.
• The diagnosis made >40years,

when patients attempting to make

occupational, marital, and other
choices and unable to deal .
• Decreases with old age.
 Histrionic personality disorder
• Excitable and emotional
• Behave in a colorful, dramatic, extroverted fashion.
• Accompanying their flamboyant aspects, often unable to maintain deep, long- lasting
attachments.

Clinical features
• high degree of attention- seeking behavior.
• exaggerate their thoughts and feelings and &
• Display temper tantrums, tears, and accusations when not the center of attention
• Seductive behavior
• Sexual fantasies are common, but filtracious.
• Their relationship -superficial, (vain, self- absorbed, and fickle)
Course-
• With age, show fewer symptoms,
• Prevalence- 1.84
• More seen in female, but not
significant.
Narcissistic personality disorder
• heightened sense of self- importance.
• grandiose feelings of uniqueness.

Clinical features

• Grandiose of self- importance.

• handle criticism poorly. (enraged or indifferent)
• Frequently ambitious to achieve fame and fortune.
• Relationship – fragile, refusal to obey conventional rules of behavior.
• They cannot show empathy.( Except to achieve their own selfish ends)
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration,
and lack of empathy, beginning by early adulthood and present in a variety of
contexts, as indicated by five or more of the following:
1. Has a grandiose sense of self- importance (eg; exaggerates achievements and
talents, expects to be recognized as superior without commensurate
achievements.
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, Course and prognosis
or ideal love.
3. Believes that he or she is “special” and unique and can only be understood by, • chronic and difficult to treat.
or should associate with, other special or high- status people (or institutions).
4. Requires excessive admiration. • Prevalence- 0-6.2%
5. Has a sense of entitlement, i.e unreasonable expectations of especially
favorable treatment or automatic compliance with his or her expectation. • 50 to 70% male.
6. Is interpersonally exploitative, ie; takes advantage of others to achieve his or
her own ends.
7. Lacks empathy: is unwilling to recognize or identify with the feelings and
needs of others.
8. Is often envious of others or believes that others are envious of him or her.
9. Shows arrogant, haughty behaviors or attitudes.
Cluster C- Anxious and fearful features
Avoidant personality disorder
extreme sensitivity to rejection socially withdrawn life.
Shy but not asocial ,great desire for companionship (uncritical acceptance)
commonly described as having an inferiority complex.
(ICD-10 uses the term anxious personality disorder.)
Clinical features
• Hypersensitivity to rejection - main personality trait is timidity.
• Desire warmth and security of human companionship, but avoidance of relationships b/o
alleged fear of rejection.
- lack of self- confidence,
- they are afraid to speak up in public or to make requests of others.
• misinterpret other persons comments as derogatory or ridiculing.
• no close friends or confidants.
Diagnostic Criteria-
• COURSE AND PROGNOSIS
A pervasive pattern of social inhibition, feelings of inadequacy, and
hypersensitivity to negative evaluation, beginning by early adulthood • Prevalence- 2.4 %
and present in a variety of contexts, as indicated by four or more of the
• Male=female
following:
1. Avoids occupational activities that involve significant interpersonal • Many are able to function in a
contact, because of fears of criticism, disapproval or rejection. protected environment.
2. Is unwilling to get involved with people unless certain of being
liked. • Some marry, have children and
3. Shows restraint within intimate relationships because of the fear of live their lives surrounded only
being shamed or ridiculed.
4. Is preoccupied with being criticized or rejected in social situations.
by family members.
5. Is inhibited in new interpersonal situations because of feelings of • when support system fail,
inadequacy.
6. Views self as socially inept, personally unappealing or inferior to
however, they are subject to
others. depression, anxiety and anger.
7. Is unusually reluctant to take personal risks or to engage in any new
activities because they may prove embarrassing • Phobic avoidance is common.
 Dependent personality disorder
• A pervasive and excessive need to be taken care of
• Leads to submissive and clinging behavior and fears of separation.
Clinical features
• a notable lack of self- confidence - often apparent in their posture, voice and mannerism
• passive and acquiescent to the desires of others.
• overly generous and thoughtful
• underplay their own attractiveness and achievements.
• may appear to others to “see the world through rose- colored glasses,” but when alone, they
may feel pessimistic, discouraged and dejected.
• avoid positions of responsibility , become anxious when forced into them.
• easily hurt by criticism and disapproval.
COURSE and PROGNOSIS
• Prevalence- 0.6 %
• More in female
• Occupational functioning tend to be
impaired, because
• They risk major depressive disorder
if they lose the person on whom they
depend,
• but with treatment the prognosis is
favorable.
Obsessive- compulsive personality disorder
• Emotional constriction, orderliness, perseverance, stubbornness, and indeciveness.
• The essential feature -a pervasive pattern of perfectionism and inflexibility.
ICD-10 uses the name anankastic personality disorder.
Clinical features:

• Preoccupied with rules,regulations,orderliness, neatness, details and achievement of perfection.

• Insist that rules to be followed rigidly and cannot tolerate what they consider infractions.
• Have limited interpersonal skills
• formal and serious and often lack humor
• eager to please those whom they see as powerful than they.
• fear making mistakes -indecisive and ruminate about making decisions
Diagnostic Criteria- Course and prognosis
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and • Prevalence- 2.1 to 7.9
interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by %
early adulthood and present in a variety of contexts as indicated by four or more of the
following • Female –more common
1. Is occupied with details, rules, lists, order, organization, or agenda to the point that the • course-variable and
key part of the activity is gone; unpredictable.
2. demonstrates perfectionism that hampers with completing tasks; • Some adolescents
3. is extremely dedicated to work and efficiency to the elimination of spare time activities; evolve into warm, open,
4. is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values; and loving adults,
5. is not capable of disposing worn out or insignificant things even when they have no • in others, can be either
sentimental meaning; the harbinger of
6. is unwilling to pass on tasks or work with others except if they surrender to exactly their schizophrenia.
way of doing things;
• Depressive disorder
7. takes on a stingy spending style towards self and others; and those of late onset is
8. shows stiffness and stubbornness. common.
Other personality disorder-
1)Passive-Aggressive Personality Disorder

Clinical features-
• Procrastinate
• Resist demands for adequate performance.
• Find excuses for delays.
• Find fault with those on whom they depend
• Refuse to extricate themselves from the dependent relationships

2)Depressive Personality Disorder:

• Pessimistic, anhedonic , duty bound, self-doubting, and chronically unhappy.
3)Sadomasochistic personality disorder:

• Characterized by elements of sadism or masochism or a combination of both.

4)Sadistic personality disorder:

• Pervasive pattern of cruel, demeaning, and aggressive behavior that is directed toward others

• Not included in DSM 5

• MEDICAL CONDITIONS ASSOCIATED WITH
PERSONALITY CHANGE
• Head trauma.
• Cerebrovascular diseases
• Cerebral tumors
• Epilepsy particularly complex partial epilepsy
• Huntington’s disease
• Multiple sclerosis
• Endocrine disorder
• Heavy metal poisoning
• Neurosyphilis
• AIDS
Management of personality disorder

Aims of treatment:
• To reduce self-harming behaviours
• To reduce behaviours that cause damage to the patient and others
• To reduce other problematic behaviours
• To improve interpersonal and social functioning
• To bring about long-term changes in personality
Assessment-
▪ Broadly two types of personality assessment methods :

▪ Projective methods :
indirect methods of personality assessment.
Usually consist of ambiguous stimuli

▪ Objective methods :
short-answer items.
Most common method
 Projective tests-
Inkblots as projective stimuli

▪The Rorschach test

Picture as projective stimuli
▪ Thematic apperception test
Word as projective stimuli
▪ Word association test
▪Sentence completion test
Sound as projective stimuli
▪ Like auditory inkblots ( skinner ,1979 )
▪ rarely used and little supporting evidence
Rorschach TAT
Objective tests-

▪ Clinical assessment.(most common method)

▪ Structured assessment tools

older instruments( MMPI,550 items; EPI. 108 items)

screening instruments(IPDS, SAP, SAPAS, PAS,)

questionnaires(MCMI, NEO-Personality inventory)

▪ Structured interviews
Several treatments are available for personality disorders .
They include:
Out-patient basis-
• Non pharmacological-Psychotherapy
• Pharmacological-Medications
• Both
Hospitalization
PSYCHOTHERAPY
• Core of care for personality disorders.
• Symptoms as a result of poor or limited coping skills - Psychotherapy aims to improve
perceptions of and responses to social and environmental stressors.

1.Psychodynamic psychotherapy (cluster A and C)

❑ examines the ways that patients perceive events(assumption: that perceptions are shaped by
early life experiences.
❑ Psychotherapy aims to identify perceptual distortions and their historical sources.
❑ facilitate the development of more adaptive modes of perception and response.
❑ Treatment - extended over a course of several years at a frequency from several times a week to
once a month.
it makes use of transference.
2.Cognitive therapy(cluster B and C)
❑ Based on the idea that cognitive errors based on long-standing beliefs influence the meaning
attached to interpersonal events.
❑ Deals with how people think about their world and their perception of it.
❑ Very active form of therapy identifies the distortions and engages the patient in efforts to
reformulate perceptions and behaviors.
❑ Typically limited to episodes of 6-20 weeks, once weekly.
❑ In the case of personality disorders, episodes of therapy are repeated often over the course of
years.
• Interpersonal therapy (IPT)
• conceives of patients' difficulties resulting from a limited range of interpersonal problems
including such issues as role definition and grief.
• Current problems are interpreted narrowly through the screen of these formulations, and
solutions are framed in interpersonal terms.
• 6-20 sessions.
• not widely practiced.
• therapists conversant in the technique are difficult to locate.
Group psychotherapy (cluster C and A)
• allows interpersonal psychopathology to display itself among peer patients
• Sessions are usually once weekly over a course (several months to years)
Dialectical behavior therapy (DBT): (In BPD)
• skills-based therapy (developed by Marsha Linehan, PhD) (individual and group formats).
• borderline personality disorder.
• manual-based therapy - development of coping skills to improve affective stability and
impulse control and on reducing self-harmful behavior.
• other cluster B personality disorders to reduce impulsive behavior.
Psycho education.
• This therapy teaches family and friends
• About the illness, including treatments, coping strategies and problem-solving skills.
 Medications
No FDA approved medications
However, several types of psychiatric medications may help with various personality disorder
symptoms.
❑ Antidepressant medications.
❑ Mood-stabilizing medications.
❑ Anti-anxiety medications.
❑ Antipsychotic medications
SYMPTOMS SYMPTOM SUBTYPE DRUG OF CHOICE CONTRAINDICATIONS

Aggression/ Affective Lithium ,serotonergic Benzodiazepines

impulsivity antidepressants,anticonvulsants,atypical
neuroleptics

Predatory Lithium , B-blocker ,ATN Benzodiazepines

Organic-like Imipramine,cholinergic agonist

Ictal CBZ,BZD,Valproate,phenytoin Neuroleptics

Mood dysregulation Emotional lability Lithium , LTG, atypicals TCA

Depression MAOIs, Antidepressants TCA

SYMPTOMS SYMPTOM SUBTYPE DRUG OF CHOICE CONTRAINDICATION
S

Anxiety Chronic cognitive Serotonergic antidepressants, MAOIs, Stimulants

Benzodiazepines

Chronic somatic MAOIs, β-Blockers, GABA analogs: Stimulants

gabapentin

Severe anxiety Low-dose neuroleptics, MAOIs Stimulants

Psychotic Acute and brief psychosis Atypical neuroleptics Stimulants

symptoms

Chronic and low-level Atypical neuroleptics

psychotic-like symptoms
HOSPITALIZATION AND RESIDENTIAL TREATMENT PROGRAMS
• In some cases, a personality disorder may be so severe that one require psychiatric
hospitalization.
• Psychiatric hospitalization is generally recommended only when one is not able to care for
oneself properly or when one is in immediate danger of harming oneself or someone else.
• Psychiatric hospitalization options include -24-hour inpatient care
- partial or day hospitalization
- residential treatment- offers a supportive place to
live.
Conclusion-
▪ Personality disorder consume large portion of community services, social welfare benefits ,
public health and prison resources.

▪ As personality disorders are ego-syntonic , it is highly unlikely that patients will continue
treatment.

▪ Combined drug and psychological treatments may be of value as there is no reason to believe
that these would be antagonistic in the treatment of personality disorder.
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Thank you…