PERSONALITY

DISORDERS
 I.
General Description of the
Disorder
PERSONALITY DISORDERS are long-
lasting, pervasive patterns of thinking,
perceiving, reacting, and relating that cause the
person significant distress or impair the person’s
ability to function.

Reference(s): American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Arlington, VA.: American Psychiatric Association
 Four Core Features (DSM-5)
1. Distorted thought patterns
2. Problematic emotional reponses
3. Poor impulse control
4. Interpersonal (relational) difficulties
General Personality Disorder
(DSM-V)
▷ An enduring pattern of inner experience and
behavior that deviates markedly from the
expectations of the individual’s culture
manifested in at least 2 of the following areas:
; Cognition
; Affectivity
; Interpersonal functioning
; Impulse control
▷ Inflexible and pervasive across a broad range of
personal and social situations
▷ May lead to clinically significant distress or
impairment in social, occupational, or other
important areas of functioning

▷ Stable and of long duration, onset can be traced

back at least to adolescence or early adulthood

▷ Pattern is not better explained as a manifestation

or consequence of another mental disorder and,

▷ Not attributable to the physiological effects of a

substance or other medical condition.
What are the common characteristics
found in people with PD?
A. Disrupted Personal Relationships
B. No feelings that they are at fault
C. Manipulative, Self-seeking, not guilty for
unethical behavior
D. Particular trait pattern that they have
developed
E. Avoidance of responsibility for problems they
create
F. Tendency to sabotage the clinical treatment
 II.
Highlights of Changes
from DSM-IV to DSM-V
 General Criteria for
Personality Disorder
(DSM-IV)
A. An enduring patterns of
inner experience and
behavior the deviates
markedly from the
expectations of the
individual's culture. This
pattern is manifested in two
(or more) of the following
areas:
1. Cognition (i.e., ways of
perceiving and interpreting
self, other people and
events)
General Criteria for
Personality Disorder
(DSM-5)
The essential features of a
personality disorder are
impairments in personality
(self and interpersonal)
functioning and the presence
of pathological personality
traits. To diagnose a
personality disorder, the
following criteria must be
met:
A. Significant impairments in
self (identity or self-direction)
and interpersonal (empathy
or intimacy) functioning.
2. Affectivity (i.e., the range,
intensity, liability, and
appropriateness of emotional
response)
3. Interpersonal functioning
4. Impulse control
B. The enduring pattern is
inflexible and pervasive
across a broad range of
personal and social
situations.
C. The enduring pattern leads
to clinically significant
distress or impairment in
social, occupational, or other
important areas of
functioning.
B. One or more pathological
personality trait domains or
trait facets.
C. The impairments in
personality functioning and
the individual’s personality
trait expression are relatively
stable across time and
consistent across situations.
D. The impairments in
personality functioning and
the individual’s personality
trait expression are not better
understood as normative for
the individual’s
developmental stage or
sociocultural environment.
D. The pattern is stable
E. The impairments in
and of long duration, and
its onset can be traced personality functioning and
back at least to the individual’s personality
adolescence or early trait expression are not
adulthood. solely due to the direct
E. The enduring pattern is physiological effects of a
not better accounted for substance (e.g., a drug of
as a manifestation or abuse, medication) or a
consequence of another general medical condition
mental disorder. (e.g., severe head trauma).
F. The enduring pattern is
not due to the direct
physiological effects of a
substance (e.g., a drug
abuse, a medication) or a
general medical condition
(e.g., head trauma).
 DSM-IV-TR Criteria for Schizotypal
Personality Disorder
Presence of five or more of the following in many
contexts beginning in early adulthood:
• Ideas of reference
• Peculiar beliefs or magical thinking
• Unusual perceptions
• Peculiar patterns of thought and speech
• Inappropriate or restricted affect
• Odd or eccentric behavior or appearance
• Lack of close friends
• Anxiety around other people, which does not
diminish with familiarity
Proposed DSM-5 Criteria for Schizotypal
Personality Disorder
Pathological personality traits in the following
domains and facets:
1. Psychoticism, characterized by eccentricity,
cognitive and perceptual dysregulation, and
unusual beliefs and experiences
2. Detachment, characterized by restricted
affectivity and withdrawal
3. Negative affectivity, characterized by
suspiciousness
The person meets criteria for a personality
disorder.
 DSM-IV-TR Criteria for Antisocial
Personality Disorder
• Age at least 18
• Evidence of conduct disorder before age 15
• Pervasive pattern of disregard for the rights of
others since the age of 15 as shown by at least
three of the following:
1. Repeated lawbreaking
2. Deceitfulness, lying
3. Impulsivity
4. Irritability and aggressiveness
5. Reckless disregard for own safety and that
of others
6. Irresponsibility as seen in unreliable
employment or financial history
7. Lack of remorse
 Proposed DSM-5 Criteria for Antisocial
Personality Disorder

Pathological personality traits in the following

domains and facets:
1. Antagonism, characterized by
manipulativeness, deceitfulness, callousness,
hostility
2. Disinhibition, characterized by
irresponsibility, impulsivity, and risk taking
The person meets criteria for a personality
disorder.
 DSM-IV-TR Criteria for Borderline
Personality Disorder
Presence of five or more of the following in many
contexts beginning in early adulthood:
• Frantic efforts to avoid abandonment
• Unstable interpersonal relationships in which
others are either idealized or devalued
• Unstable sense of self
• Self-damaging, impulsive behaviors in at least
two areas, such as spending, sex, substance
abuse, reckless driving, binge eating
• Recurrent suicidal behavior, gestures, or self-
injurious behavior
• Chronic feelings of emptiness
• Recurrent bouts of intense or poorly controlled
anger
• During stress, a tendency to experience transient
paranoid thoughts and dissociative symptoms
Proposed DSM-5 Criteria for Borderline
Personality Disorder
Pathological personality traits in the following
domains and facets:
1. Negative affectivity, characterized by
emotional lability, anxiousness, separation
insecurity, and depressivity
2. Disinhibition, characterized by impulsivity
and risk taking
3. Antagonism, characterized by hostility
The person meets criteria for a personality
disorder.
 DSM-IV-TR Criteria for Narcissistic
Personality Disorder
Presence of five or more of the following shown by
early adulthood in many contexts:
• Grandiose view of one’s importance
• Preoccupation with one’s success, brilliance,
beauty
• Belief that one is special and can be understood
only by other high-status people
• Extreme need for admiration
• Strong sense of entitlement
• Tendency to exploit others
• Lack of empathy
• Envious of others
• Arrogant behavior or attitudes
Proposed DSM-5 Criteria for Narcissistic
Personality Disorder
Pathological personality traits in the following
domain and facets:
1. Antagonism, characterized by grandiosity
and attention seeking
The person meets criteria for a personality disorder
 DSM-IV-TR Criteria for Avoidant
Personality Disorder
A pervasive pattern of social inhibition, feelings of
inadequacy, and hypersensitivity to criticism as
shown by four or more of the following starting in
early adulthood in many contexts:
• Avoidance of occupational activities that involve
significant interpersonal contact, because of
fears of criticism or disapproval
• Unwilling to get involved with people unless
certain of being liked
• Restrained in intimate relationships because of
the fear of being shames or ridiculed
• Preoccupation with being criticized or rejected
• Inhibited I new interpersonal situations because
of feelings of inadequacy
• Views self as socially inept or inferior
• Unusually reluctant to try new activities
because they may prove embarrassing
 Proposed DSM-5 Criteria for Avoidant
Personality Disorder
Pathological personality traits in the following
domain and facets:
1. Detachment, characterized by withdrawal,
intimacy avoidance, and anhedonia
2. Negative affectivity, characterized by
anxiousness
The person meets criteria for a personality disorder
 DSM-IV-TR Criteria for Obsessive-
Compulsive Personality Disorder
Intense need for order and control, as shown by the
presence of at least four of the following beginning
by early adulthood and evidenced in many contexts:
• Preoccupation with rules, details, and
organization to the extent that the point of an
activity is lost
• Extreme perfectionism interferes with task
completion
• Excessive devotion to work to the exclusion of
leisure and friendships
• Inflexibility about morals and values
• Difficulty discarding worthless items
• Reluctance to delegate unless others conform to
one’s standards
• Miserliness
• Rigidity and Stubbornness
Proposed DSM-5 Criteria for Obsessive-
Compulsive Personality Disorder
Pathological personality traits in the following
domain and facets:
1. Compulsivity, characterized by rigid
perfectionism
2. Negative affectivity, characterized by
perseveration
The person meets criteria for a personality disorder
 III.
Etiology and Theoretical
Perspectives
GENETIC FACTORS:
▷ For Cluster A personality disorders, it is most
commonly found in the biological relatives of
patients with Schizophrenia than in controlled
groups.

▷ Genetic base is also associated with the Cluster B

personality disorders.

▷ Cluster C personality disorders may also have a

genetic base.

▷ There is a genetic link to aggression, anxiety, and

fear.
BIOLOGICAL FACTORS:

▷ Hormones

▷ Platelet Monoamine Oxidase

▷ Smooth Pursuit Eye Movements

▷ Neurotransmitters

▷ Electrophysiology
PSYCHOANALTYIC FACTORS:
▷ As suggested by Sigmund Freud, personality traits
are related to a fixation at one psychosexual
stage of development.

▷ Wilhelm Reich coined the term “character armor” to

describe the defensive style of a person for
protecting themselves from internal impulses and
from interpersonal anxiety in significant
relationships.

▷ The behavior of people with personality disorders

are EGO SYNTONIC: creates no distress for them
even if it may adversely affect others.
▷ DEFENSE MECHANISMS: the unconscious mental
processes that the ego uses to resolve conflicts
among the four lodestars of the inner life: instincts
(wish or need), reality, important persons, and
conscience.

FANTASY: seek solace and satisfaction within

themselves by creating imaginary lives,
especially imaginary friends.
DISSOCIATION: a Pollyanna-like replacement
of unpleasant effect with pleasant ones.
ISOLATION: remembers the truth in fine
detail but without affect.
PROJECTION: attribute their own
unacknowledged feelings to others.
SPLITTING: feelings are divided into either all
good or all bad.
PASSIVE AGGRESSION: turn their anger
against themselves, also called as masochism.
ACTING OUT: directly express unconscious
wishes or conflicts through action to avoid
being conscious of either the accompanying
idea or the effect.
PROJECTIVE IDENTIFICATION: an aspect of
the self is projected onto someone else.
VERBAL ABUSE: may likely have BPD, NPD,
OCPD, or PPD.
 CLUSTER A:
“Odd, eccentric cluster” / “Weird””
Paranoid Personality Disorder
▷ “Mistrust and suspicion” / “Accusatory”

ETIOLOGY AND THEORETICAL PERSPECTIVE

Genetically Predisposed
 Clinical Features
A. A pervasive distrust and suspiciousness of
others such that their motives are interpreted as
malevolent, beginning by early adulthood and
present in a variety of contexts, as indicated by
four (or more) of the following:
1. Suspects, without sufficient basis, that
others are exploiting, harming, or deceiving
him or her.
2. Is preoccupied with unjustified doubts
about the loyalty or trustworthiness of friends
or associates.
3. Is reluctant to confide in others because of
unwarranted fear that the information will be
used maliciously against him or her.
4. Reads hidden demeaning or threatening
meanings into benign remarks or events.
5. Persistently bears grudges.
6. Perceives attacks on his or her character or
reputation that are not apparent to others and
is quick to react angrily or counterattack.
7. Have recurrent suspicions, without
justification, regarding fidelity of spouse or
sexual partner.
B. Does not occur exclusively during the course of
schizophrenia, a bipolar disorder or depressive
disorder with psychotic features, or another
psychotic disorder and is not attributable to the
physiological effects of another medical condition.

Note: If criteria are met prior to the onset of

schizophrenia, add “premorbid”, i.e., “paranoid
personality disorder (premorbid).”
 Course and Prognosis
▷ May be first apparent in childhood and
adolescence with solitariness, poor peer
relationships, social anxiety, underachievement
in school, hyper-sensitivity, peculiar thoughts and
language, and idiosyncratic fantasies.
▷ May appear to be “odd” or “eccentric” and attract
teasing.
▷ More commonly diagnosed in males.
▷ May be life-long; may be a harbinger of
schizophrenia.
▷ Occupational and marital problems are common.
 Treatment
PSYCHOTHERAPY:
- Therapists should be straightforward when
dealing with patients with PPD.
- If accused of inconsistency, honesty and an
apology are preferred to a defensive
explanation.
- REMEMBER: trust and toleration of intimacy
are troubled areas for patients with PPD.
- Requires a professional and not overly warm
style from therapists.
 - Patients with PPD usually do not do well in
group psychotherapy, but can be useful for
improving social skills and diminishing
suspiciousness through roleplay.
PHARMACOTHERAPY:
- Useful in dealing with agitation and anxiety.
- Antianxiety agent such as diazepam (Valium)
suffices.
- Necessary to use an antipsychotic such as
haloperidol (Haldol) in small dosages to
manage severe agitation or quasi-delusional
thinking.
- The antipsychotic drug pimozidle (Orap) is
successful in reducing paranoid ideation.
Schizoid Personality Disorder
▷ “Disinterest in others” / “Aloof”

ETIOLOGY AND THEORETICAL PERSPECTIVE

Genetically Predisposed
 Clinical Features
A. A pervasive pattern of detachment from social
relationships and a restricted range of expression of
emotions in interpersonal settings, beginning by
early adulthood and present in a variety of contexts,
as indicated by four (or more) of the following:
1. Neither desires nor enjoys close
relationships, including being part of a family.
2. Almost always chooses solitary activities.
3. Has little, if any, interest in having sexual
experiences with another person.
4. Takes pleasure in few, if any, activities.
 5. Lacks close friends or confidants other than
first-degree relatives.
6. Appears indifferent to the praise or criticism
of others.
7. Shows emotional coldness, detachment, or
flattened affectivity.

B. Does not occur exclusively during the course of

schizophrenia, a bipolar disorder or depressive
disorder with psychotic features, another psychotic
disorder, or autism spectrum disorder and is not
attributable to the physiological effects of another
medical condition.
Note: If criteria are met prior to the onset of
schizophrenia, add “premorbid”, i.e., “schizoid
personality disorder (premorbid).”
 Course and Prognosis
▷ Onset usually occurs in early childhood or
adolescence.
▷ Along with all personality disorders, Schizoid
Personality Disorder is long lasting but not
necessarily life-long.
▷ Proportion of patients who incur schizophrenia is
unknown.
 Treatment
PSYCHOTHERAPY:
- Tend toward introspection.
- As trust develops, they my reveal a plethora
of fantasies, imaginary friends, and fears of
unbearable dependence.
- In group therapy settings, they may be silent
for long periods but do become involved
nonetheless.
- Group therapy may provide the only social
contact in their isolated existence.
PHARMACOTHERAPY:
- Small dosages of antipsychotics,
antidepressants, and psychostimulants has
benefitted some patients.

- Serotonergic agents may make patients less

sensitive to rejection.

- Benzodiazepines may help diminish

interpersonal anxiety.
 Schizotypal Personality
Disorder
▷ “Odd or eccentric” / “Awkward”

ETIOLOGY AND THEORETICAL PERSPECTIVE

Genetically Predisposed
 Clinical Features
A. A pervasive pattern of social and interpersonal
deficits marked by acute discomfort with, and
reduced capacity for, close relationships as well as
by cognitive or perceptual distortions and
eccentricities of behavior, beginning by early
adulthood and present in a variety of contexts, as
indicated by five (or more) of the following:

1. Ideas of reference (excluding delusions of

reference).
2. Odd beliefs or magical thinking that
influences behavior and is inconsistent with
subcultural norms (e.g., superstitiousness,
belief in clairvoyance, telepathy, or “sixth
sense”: in children and adolescents, bizarre
fantasies or preoccupations).
3. Unusual perceptual experiences, including
bodily illusions.
4. Odd thinking and speech (e.g., vague,
circumstantial, metaphorical, overelaborate,
or stereotyped).
5. Suspiciousness or paranoid ideation.
6. Inappropriate or constricted affect.
 7. Behavior or appearance that is odd,
eccentric, or peculiar.
8. Lack of close friends or confidants other
than first-degree relatives.
9. Excessive social anxiety that does not
diminish with familiarity and tends to be
associated with paranoid fears rather than
negative judgments about self.
B. Does not occur exclusively during the course of
schizophrenia, a bipolar disorder or depressive
disorder with psychotic features, another psychotic
disorder, or autism spectrum disorder.
Note:
If criteria are met prior to the onset of
schizophrenia, add “premorbid,” e.g., “schizotypal
personality disorder (premorbid).
 Course and Prognosis
▷ Relatively stable course, with only a small
proportion of individuals going on to develop
schizophrenia or another psychotic disorder.
▷ First apparent in childhood and adolescence.
▷ Schizotype is the premorbid personality of the
patient with schizophrenia.
▷ Some patient maintain a stable Schizotypal
personality throughout their lives and marry and
work despite their oddities.
 Treatment
PSYCHOTHERAPY:
- Does not differ from the treatment of those
with Schizoid Personality Disorder, but must
deal sensitively with those who have
Schizotypal Personality Disorder.
- Patients have peculiar patterns of thinking
and some may be involved in cults, strange
religious practices, and the occult.
- Must not ridicule such activities or be
judgmental about their beliefs or activities.
PHARMACOTHERAPY:
- Antipsychotic medication may be useful in
dealing with ideas of reference, illusions, and
other symptoms of the disorder and can be
used in conjunction with psychotherapy.
- Antidepressants are useful when a
depressive component of personality is
present.
 CLUSTER B:
“Dramatic, emotional cluster” / “Wild”
Antisocial Personality Disorder
▷ Social irresponsibility, disregard for others, and
deceitfulness and manipulation of others for
personal gain.
 Etiology
▷ The hereditable factor is about 80%
▷ Associated with alcohol use disorders
▷ Malnutrition in early life

▷ 100% genetic overlap between the maladaptive

trait domains with ASPS ( Kienneud, 2013)
 Clinical Features
A. A pervasive pattern of disregard for and violation
of the rights of others, occurring since age 15 year,
as indicated by three (or more) of the following:
1. Violation of social norms, and breaking the
law.
2. Deceitfulness.
3. Impulsivity or failure to plan ahead.
4. Irritability and aggressiveness.
5. Reckless disregard for safety of self or
others.
6. Consistent irresponsibility.
7. Lack of remorse.
B. The individual is at least age 18 years.
C. There is evidence of conduct disorder with onset
before age 15 years.
D. The occurrence of antisocial behavior is not
exclusively during the course of schizophrenia or
bipolar disorder.
 Course and Prognosis
▷ Antisocial behaviors typically have their onset
before age 8 years.
▷ Nearly 80% of people with ASPS developed their
first symptom by age 11.
▷ Boys develop symptoms earlier than girl.
(Black, 2015)
▷ Prognosis varies and decrease as person grow
older. (Synopsis, 2015)
▷ Have somatization disorder and multiple physical
complaints.
▷ Depressive, alcohol use, and other substance
abuse disorders are common.
 Treatment
PSYCHOTHERAPY:
- CBT
- Self-help groups are more useful than jails in
alleviating the disorder.
PHARMACOTHERAPY:
- If shows evidence of hyperactivity disorder,
methylphenidate (Ritaline) is useful.
- Control impulsive behavior with antiepileptic
drugs such as carbamazepine (Tegretol) and
valproate (Depakote).
- β-Adrenergic receptor antagonists have been
used to reduce aggression.
Borderline Personality Disorder
▷ Unstable moods, interpersonal relationships,
self-image, and behavior
 Etiology
▷ Prefrontal cortex is smaller than normal
▷ Amygdala seems to be overactive
▷ Childhood trauma such as sexual, emotional, or
physical abuse
▷ Parental Style
Marsha Linehan’s Diathesis- Stress
Theory of BPD
 Clinical Features
A. A pervasive pattern of instability of interpersonal
relationships, self-mage, and affects, and marked
impulsivity, beginning by early adulthood and
present in a variety of contexts, if 5 or more of the
following is present:
1. Frantic effort to avoid real or imagined
abandonment.
2. A pattern of unstable and intense
interpersonal relationships.
3. Identity disturbance.
4. Impulsivity in at least two areas that are
potentially self-damaging.
5. Recurrent suicidal behavior, gestures, or
threats, or self-mutilating behavior.
6. Affective instability due to a marked
reactivity of mood.
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger, or difficulty
controlling anger.
9. Transient, stress-related paranoid ideation
or severe dissociative symptoms.
 Course and Prognosis
▷ BDP is fairly stable, only change little over time.
( Synopsis, 2014)
▷ Chronic instability in early adulthood, with
episodes of serious affective and impulsive
dyscontrol and high levels of use of health and
mental health resources.
▷ The remission rate of BPD went from 30 to 50
percent by the second year follow-up, up to 80
percent by the tenth year.
○ ( Biskin, 2015)
 Treatment
PSYCHOTHERAPY:
Dialectical Behavior Therapy (DBT):
A type of cognitive behavioral treatment. It
emphasizes individual psychotherapy and group
skills training classes to help people learn and use
new skills and strategies to develop a life that they
experience as worth living.

Mentalization-based Treatments (MBT):

To help patients build relationship skill as they
learn to better regulate their thoughts and feelings.
Transference-focused Psychotherapy (TFP):
A modified form of psychodynamic
psychotherapy that is based on Otto Kernberg’s
object relations theory.
PHARMACOTHERAPY:
- Antipsychotics are used to control anger,
hostility, and brief psychotic episodes.
- Antidepressants.
- MAO inhibitors (MAOIs) to modulate
impulsive behavior.
- Benzodiazepines like alprazolam (Xanax).
- Anticonvulsants such as carbamazepine
- Selective Serotonin Reuptake Inhibitors
(SSRIs)
Histrionic Personality Disorder
▷ Attention seeking and dramatic behavior
 Etiology and Theoretical
Perspective
▷ Genetic Factor
Developmental Causes:
▷ Psychosexual: psychoanalysts proposed that the
genital phase, Freud's fifth or last stage of
psychosexual development, is a determinant of
HPD
▷ Psychosocial: Most psychoanalysts agree that a
traumatic childhood contributes towards the
development of HPD. Some theorists suggest that
the more severe forms of HPD derive from
disapproval in the early mother-child relationship
Biosocial Learning Causes:
▷ Arise from unconscious patterns of
reinforcement provided by parents and others.
▷ Histrionic person believe that potential
caregivers are not trustful and should be
manipulated instead.
▷ Social cultures that tend to value uninhibited
displays of emotion.
 Clinical Features
A. Excessive emotionality and attention seeking,
beginning by early adulthood and present in variety
of context if five or more are prevalent:
1. Is uncomfortable in situations in which she
or he is not the center of attention.
2. Interaction with others is often
characterized by inappropriate sexually
seductive or provocative behavior.
3. Display rapidly shifting and shallow
expression of self.
4. Consistently uses physical appearance to
draw attention to self.
5. Has a style of speech that is excessively
impressionistic and lacking in detail.
6. Shows self-dramatization, theatricality, and
exaggerated expression of emotion.
7. Is suggestible (i.e. easily influenced by others
or circumstances).
8. Considers relationships to be more intimate
than they actually are.
 Course and Prognosis
▷ With age, patient show fewer symptoms because
they lack the energy of earlier years.

▷ Sensation seekers.

▷ May get in trouble with the law, abuse substances,

and act promiscuously.
 Treatment
PSYCHOTHERAPY:
- Patients with HPD are often unaware of their
own real feelings, clarification of their inner
feeling is an important therapeutic process.
- Psychoanalytic therapy
- Cognitive-behavioral therapy
- Group therapy
- Family therapy
PHARMACOTHERAPY:
- Antipsychotics for derealizations and
illusions.

- Antidepressants for depression and somatic

complaints.

- Anxiety agents for anxiety.

Narcissistic Personality Disorder
▷ Fragile self-esteem, a need to be admired, and an
inflated view of self-worth (called grandiosity)
 Etiology and Theoretical
Perspective
▷ Less volume of gray matter in the left anterior
insular, the part of the brain related to empathy,
emotional regulation, compassion, and cognitive
functioning.
▷ In the classic model, narcissism functions as a
defense against awareness of low self-esteem.
▷ May arise from an imbalance between positive
mirroring of the developing child and the presence
of an adult figure who can be idealized.
 Clinical Features
A pervasive pattern of grandiosity (in fantasy or
behavior), need for admiration, and lack of empathy,
beginning by early childhood and present in a variety
of contexts, as indicated by five (or more) of the
following:
1. Has a grandiose sense of self-importance.
2. Is preoccupied with fantasies or unlimited
success, power, brilliance beauty, or ideal love.
3. Believes that he or she is “special” and
“unique” and can only be understood by, or
should associate with other special people.
4. Requires excessive admiration.

5. Has a sense of entitlement.

6. Is interpersonally exploitative.

7. Lacks empathy.

8. Is often envious of others or believes that

others are envious of him or her.

9. Shows arrogant, haughty behaviors or

attitudes.
 Course and Prognosis
▷ Narcissistic Personality Disorder is chronic and
difficult to treat.

▷ Patients with NPD must constantly face the

consequences of their maladaptive behaviors.

▷ Experience more midlife crises due to their

vulnerability.
 Treatment
PSYCHOTHERAPY:
- Treatment of NPD is difficult because they
must renounce their narcissism to make
progress.
- Some psychiatrists uses psychoanalytic
approach.
- Group therapy is advocated by others to help
people with NPD to learn how to share and
develop empathetic response to others.
PHARMACOTHERAPY:
- Lithium (Eskalith) has been used with
patients with mood swings.

- Since patients with NPD tolerate rejection

poorly and are susceptible to depression,
antidepressants, especially serotonergic
drugs, may also be of use.
 CLUSTER C:
“Anxious, fearful cluster” / “Worried”
 Avoidant Personality Disorder
▷ Avoidance of interpersonal contact due to fear of
rejection / “Cowardly”
 Etiology and Theoretical
Perspective
▷ Expression of extreme traits of introversion and
neuroticism.

▷ No available data on biologic causes.

▷ A diagnostic overlap with social phobia exists.

 Clinical Features
A pervasive pattern of social inhibition, feelings of
inadequacy, and hypersensitivity to negative
evaluation, beginning by early adulthood and
present in a variety of contexts, as indicated by four
(or more) of the following:
1. Avoids occupational activities that involve
significant interpersonal contact because of
fears of criticism, disapproval, or rejection.
2. Is unwilling to get involve with people unless
certain of being liked.
3. Shows restraint within intimate
relationships because of the fear of being
shamed or ridiculed.
4. Is preoccupied with being criticized or
rejected in social situations.
5. Is inhibited in new interpersonal situations
because of feelings of inadequacy.
6. Views self as socially inept, personally
unappealing, or inferior to others.
7. Is unusually reluctant to take personal risks
or to engage in any new activities because
they may prove embarrassing.
 Course and Prognosis
▷ Often starts in infancy or childhood with shyness,
isolation, and fears of strangers and new situations.
▷ For individuals who develops APD, they may
become increasingly shy and avoidant during
adolescence and early adulthood when social
relationships with new people become especially
important.
▷ Diagnosis should be used with great caution in
children and adolescence for their shy and avoidant
behavior may be developmentally appropriate.
 Treatment
PSYCHOTHERAPY:
- Psychotherapeutic treatment depends on
solidifying an alliance with patients.
- Cognitive Behavioral therapy (CBT)
- Talk therapy
- Group therapy may help patients
understand how their sensitivity to rejection
affects them and others.
- Assertiveness training
PHARMACOTHERAPY:
- used to manage anxiety and depression when
associated with the disorder.
- β-adrenergic receptor antagonists such as
atenolol (Tenormin)
- Serotonergic agents
- Dopaminergic drugs
Dependent Personality Disorder
▷ Submissiveness and dependency, “Clingy”
 Etiology and Theoretical
Perspective
▷ Studies of genetics or of biologic traits have been
conducted.

▷ Psychodynamic
 Clinical Features
A pervasive and excessive need to be taken care of
that leads to submissive and clinging behavior and
fears of separation, beginning by early adulthood
and present in a variety of contexts, as indicated by
five (or more) of the following:
1. Has difficulty making everyday decisions
without an excessive amount of advice and
reassurance from others.
2. Needs others to assume responsibility for
most major areas of his or her life.
3. Has difficulty expressing disagreement with
others because of fear of loss of support or
approval.
4. Has difficulty initiating projects or doing
things on his or her own
5. Goes to excessive lengths to obtain
nurturance and support from others, to the
point of volunteering to do things that are
unpleasant.
6. Feels uncomfortable or helpless when alone
because of exaggerated fears of being unable
to take care for himself or herself.
7. Urgently seeks another relationship as a
source of care and support when a close
relationship ends.

8. Is unrealistically preoccupied with fears of

being left to take care of himself or herself.
 Course and Prognosis
▷ Diagnosis should be used with great caution with
children and adolescents.
▷ Occupational functioning tends to be impaired.
▷ Social relationships are limited to those on whom
they can depend.
▷ May be at risk for major depressive disorder
 Treatment
PSYCHOTHERAPY:
- Cognitive Behavioral therapy (CBT)
- Psychodynamic therapy
- Insight-oriented therapies
- Behavioral therapy
- Assertiveness training
- Family therapy
- Group therapy
- Must show great respect for these patients’
feelings of attachment
PHARMACOTHERAPY:
- Used to deal with specific symptoms such as
anxiety and depression.
- Imipramine (Tofranil)
- Benzodiazepines and serotonergic agents
- Psychostimulants
 Obsessive-Compulsive
Personality Disorder
▷ Perfectionism, rigidity, and obstinacy,
“Compulsive”
 Etiology and Theoretical
Perspective
▷ Genetically Predisposed
▷ Psychodynamic Perspective
 Clinical Features
A pervasive pattern of preoccupation with
orderliness, perfectionism, and mental and
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:
1. IS preoccupied with details, rules, list, order,
organization, or schedules to the extent that
the major point of the activity is lost.
2. Shows perfectionism that interfered with
task completion.
3. Is excessively devoted to work and
productivity to the exclusion of leisure
activities and friendships.
4. Is overconscientious, scrupulous, and
inflexible about matters of morality, ethics, or
values.
5. Is unable to discard worn-out or worthless
objects even when they have no sentimental
value.
6. Is reluctant to delegate tasks or work with
others unless they submit to exactly his or her
way of doing things.
7. Adopts a miserly spending style toward
both self and others; money is viewed as
something to be hoarded for future
catastrophes.
8. Shows rigidity and stubbornness.
 Course and Prognosis
▷ Unpredictable
▷ Character neurosis
 Treatment
PSYCHOTHERAPY:
- Treatment is often long and complex and
may encounter countertransference
problems.
- Psychodynamic therapy
- Cognitive Behavioral therapy (CBT)
- Group therapy and behavior therapy
PHARMACOTHERAPY:
- Clonazepam (Klonopin), anticonvulsant
- Clomipramine (Anafranil)
- Serotonergic agents (e.g. fluoxetine)
- Nefazodone (Serzone)
Other Personality
Disorders
 Personality Change due to
Another Medical Condition
Diagnostic Criteria:

A. A persistent personality disturbance that

represents a change from the individual’s
previous characteristic personality pattern.

Note: In children, the disturbance involves a marked

deviation from normal development or a significant
change in the child’s usual behavior patterns, lasting
at least 1 year.
B. There is evidence from the history, physical
examination, or laboratory findings that the
disturbance is the direct pathophysiological
consequence of another medical condition.
C. The disturbance is not better explained by
another mental disorder (including another mental
disorder due to another medical condition).
D. The disturbance does not occur exclusively
during the course of a delirium.
E. The disturbance causes clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.
Specify whether:
Labile type: If the predominant feature is affective
lability.

Disinhibited type: If the predominant feature is poor

impulse control as evidenced by sexual
indiscretions, etc.

Aggressive type: If the predominant feature is

aggressive behavior.

Apathetic type: If the predominant feature is marked

apathy and indifference.
Paranoid type: If the predominant feature is
suspiciousness or paranoid ideation.

Other type: If the presentation is not characterized

by any of the above subtypes.

Combined type: If more than one feature

predominates in the clinical picture.

Unspecified type
 Medical Conditions Associated with
Personality Change
• Head trauma
• Cerebrovascular diseases
• Cerebral tumors
• Epilepsy
• Huntington’s disease
• Multiple sclerosis
• Endocrine disorders
• Heavy metal poisoning
• Neurosyphilis
• Acquired immune deficiency syndrome (AIDS)
 Other Specified Personality
Disorder
Used in situations in which the clinician chooses
to communicate the specific reason that the
presentation does not meet the criteria for any
specific personality disorder.
Unspecified Personality Disorder
Used in situations in which the clinician chooses
not to specify the reason that the criteria are not
met for specific personality disorder, and
includes presentations in which there is
insufficient information to make a more specific
diagnosis.
 VII.
Assessment Strategy
 Cluster A: Manifestations and
Management Strategies
PARANOID:
Adopt a professional stance, provide clear
explanations, be empathetic to fears, avoid
direct challenge to paranoid ideation.

SCHIZOID:
Adopt a professional stance, provide clear
explanations, avoid overinvolvement in
personal and social issues.
SCHIZOTYPAL:
Adopt a professional stance, provide clear
explanations, tolerate odd beliefs and
behaviors, avoid overinvolvement in personal
and social issues.
 Cluster B: Manifestations and
Management Strategies
ANTISOCIAL:
Carefully investigate concerns and motives,
communicate in a clear and nonpunitive
manner, set clear limits.
BORDERLINE:
Avoid excessive familiarity, schedule regular
visits, provide clear, nontechnical
explanations, tolerate angry outbursts, but set
limits, maintain awareness of personal
feelings, consult psychiatrist.
HISTRIONIC:
Avoid excessive familiarity, show professional
concern for feelings, emphasize objective
issues.

NARCISSISTIC:
Validate concerns, give attentive and factual
responses to questions, channel patient’s skills
into dealing with illness.
 Cluster C: Manifestations and
Management Strategies
AVOIDANT:
Provide reassurance, validate concerns,
encourage reporting of symptoms and
concerns.
DEPENDENT:
Provide reassurance, schedule regular check-
ups, set realistic limits on availability, enlist
others to support patient, avoid rejection of
patient.
OBSSESSIVE-COMPULSIVE:
Complete thorough history and examinations,
provide thorough explanations, do not
overemphasize uncertainty, encourage
patient participation in treatment.
Thanks!