PERSONALITY DISORDERS

by DSM IV

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 PDs Characteristics
 Presence of long-standing, rigid, unsuitable
pattern of relating to others
 Presence of personality characteristics that
cause social and occupational impairment
 Lack of insight
 Failure to seek psychological help unless
compelled by others
 Absence of frank psychosis

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Personality Disorder Clusters
 There are three clusters

1. Cluster A:
 Patient is eccentric and/or fears social
relationships
 Includes:
– Paranoid personality disorder
– Schizoid personality disorder
– Schizotypal personality disorder

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2. Cluster B
 Patient is emotional, erratic, and/or dramatic
 Includes:
– Histrionic personality disorder
– Narcissistic personality disorder
– Antisocial personality disorder
– Borderline personality disorder

3. Cluster C
 Patient is fearful and/or anxious
 Includes:
– Avoidant personality disorder
– Obsessive-compulsive personality disorder
– Dependent personality disorder

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 Epidemiology
 Personality disorder is prevalent in @ 1% of
population
 Schizoid personality disorder may be less
common
 More common (slightly) are
– Dependent personality disorder
– Schizotypal personality disorder
– Histrionic personality disorder
 Symptoms must be present by early adulthood for
diagnosis
 Antisocial personality disorder can not diagnosed
until 18 years of age 5
 Relatives of patients with personality disorders
may have other psychiatric disorders:

1. Schizoid, Schizotypal and Parannoid – schizophrenia

2. Paranoid - delusional disorder (persecutory type)
3. Antisocial – substance abuse and somatization
disorders
4. Borderline -- Mood disorders, substance abuse and
antisocial personality disorder
5. Avoidant -- anxiety disorder

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 The patients with PDs have excessive use of maladaptive
or inappropriate defense mechanisms
 Prognosis for these patients is that the disease is chronic
and lifelong
 Medication for these patients are not useful except in
borderline personality disorder
 Medication is usually for symptoms associated with
depression and anxiety
 It is important to remember that PD patients have a high
potential for addiction THEREFORE--- BE CAUTIOUS
WHEN PRESCRIBING MEDICATIONS

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 PARANOID PERSONALITY
DISORDER
 PATIENT WITH THIS DISORDER ARE:
– SUSPICIOUS
– MISTRUSTFUL
– LITIGIOUS
– ATTRIBUTES RESPONSIBILTY FOR PROBLEMS
TO OTHERS
 DEFENSE MECHANISM USED ARE
– PROJECTION
– DENIAL

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 TYPICAL PATIENT PRESENTATION

50 YEAR-OLD OFFICE WORKER TELLS YOU

THAT HE HAS NEVER BEEN PROMOTED
BECAUSE HIS CO-WORKERS FREQUENTLY
CLAIM HIS IDEAS AS THEIR OWN. WHEN
HE IS FIRED FOR POOR PERFORMANCE, HE
FILES A LAWSUIT AGAINST THE
COMPANY

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Schizoid Personality Disorder
 These patients have a life long pattern of
voluntary social withdrawal
 Similar to delusional disorder and
schizophrenia but without frank psychotic
symptoms
 In the young can be mistaken for mild
autistic disorder

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TYPICAL PATIENT PRESENTATION

48 YEAR-OLD MAN IS CONTENT

LIVING ALONE IN AN ISOLATED
CABIN, GROWING HIS OWN FOOD,
AND RARELY HAVING CONTACT
WITH OTHERS

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SCHIZOTYPAL PERSONALITY
DISORDER
 THESE PATIENTS HAVE:
– PECULIAR APPEARANCE
– MAGICAL THINKING
– ODD THOUGHT PATTERNS AND
BEHAVIOR WITHOUT PSYCHOSIS
– MAJOR DEPRESSION COULD BE FOUND
(CO-MORBIDEDLY) IN THESE PATIENTS

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 DENIAL AND PROJECTION ARE USED
AS DEFENSE MECHANISMS

– DELUSIONAL DISORDER
– SCHIZOPHRENIA
– MOOD DISORDER WITH PSYCHOSIS

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 TYPICAL PATIENT PRESENTATION

35 YEAR-OLD MALE PATIENT TELLS

YOU THAT HE NEVER STEPS ON
CRACKS IN THE SIDEWALK TO
AVOID “BREAKING HIS MOTHER’S
BACK”(MAGICAL THINKING). HE
SEEMS ODD, SAYS THAT HE OFTEN
FEELS UNCOMFORTABLE IN SOCIAL
SITUATIONS AND HAS FEW FRIENDS

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HISTRIONIC PERSONALITY
DISORDER
 THESE PATIENTS ARE:

– EXTROVERTED
– EMOTIONAL
– DRAMATIC
– SEXUALITY PROVOCATIVE (LIFE OF THE
PARTY)
– INABILITY TO MAINTAIN INTIMATE
RELATIONSHIPS
– “DON JUAN” BEHAVIOR IN MEN

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 DEFENSE MECHANISM:
– REPRESSION
– REGRESSION
– SOMATIZATION
1. BORDERLINE PD: SHOULD INCLUDE CHRONIC
FEELINGS OF BOREDOM, EMPTINESS AND
SUICIDAL BEHAVIORAL
2. NARCISSISTIC PD: SHOULD INCLUDE FEELINGS
OF SUPERIOITY
3. DEPENDENT PD: NO FLAMBOYANCE OR AN
OVERLY EMOTIONAL STATE
4. HYPOMANIC EPISODE IN BIPOLAR II OR
CYCLOTHYMIC DISORDER: SYMPTOMS REMIT
WHEN THE EPISODE ENDS

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 TYPICAL PATIENT PRESENTATION

25 YEAR-OLD FEMALE PATIENT COMES TO

YOUR OFFICE DRESSED IN A LOW – CUT
BLOUSE AND VERY SHORT SKIRT AND
BRINGS A GIFT FOR YOU. SHE FISHES FOR
COMPLIMENTS FROM THE OFFICE STAFF
AND TELLS YOU THAT YESTERDAY SHE
“ALMOST BLED TO DEATH” WHEN SHE
CUT HER FINGER.

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 Narcissistic Personality
Disorder
 These patients are:
– Grandiose
– Envious
– Has sense of special entitlement
– Lack empathy
 Defense Mechanism:
– Denial
– Displacement
– Poor ego functioning

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– Histrionic PD and Borderline PD [ include
emotionality and instability]

– Obsessive – Compulsive PD [includes feelings

of imperfection]

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TYPICAL PATIENT PRESENTATION

40 YEAR – OLD MALE PATIENT TELLS

YOU THAT BECAUSE YOU ARE A
DOCTOR, YOU CAN UNDERSTAND
THAT HE IS “ BETTER THAN MOST
PEOPLE.” HE THEN ASKS TO BE
REFERRED TO A PHYSICIAN WHO
GRADUATED FROM AN IVY LEAGUE
SCHOOL.

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ANTISOCIAL PERSONALITY
DISORDER
 THESE PATIENTS ARE:
– ALSO KNOWN AS SOCIOPATHS OR
PSYCHOPATH
– UNWILLING TO CONFORM TO SOCIAL
NORMS
– FAIL TO LEARN FROM EXPERIENCES
– ASSOCIATED WITH CONDUCT
DISORDER IN CHILDHOOD
– CRIMINALITY IN ADULTHOOD
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 DEFENSE MECHANISM:
– INADEQUATE SUPEREGO FUNCTIONING

Problems:
– SUBSTANCE ABUSE
– CRIMINAL BEHAVIOR
– NARCISSISTIC PD
– PARANOID PD
– HYPOMANIC EPISODE IN BIPOLAR II OR
CYCLOTHYMIC DISORDERS
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 TYPICAL PATIENT PRESENTATION

A 29 YEAR- OLD MAN TELLS YOU THAT HE

HAS STOLEN VALUABLE ITEMS FROM
FRIENDS AND FAMILY ON MANY
OCCASSIONS WITH NO INTENTION OF
RETURNING THEM AND WITHOUT
CONCERN FOR THE PEOPLE HE STOLE
FROM. HE HAS BEEN UNEMPLOYED ON
AND OFF FOR MANY YEARS AND HAS
BEEN ARRESTED ON A VARIETY OF
MINOR CHARGES.

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BORDERLINE PERSONALITY
DISORDER
 THESE PATIENTS ARE:
– UNSTABLE BEHAVIOR AND MOOD
– BOREDOM, EMPTINESS
– FEELINGS OF ALONENESS
– IMPULSIVENESS
– SUICIDE ATTEMPTS
– BRIEF PERIOD OF LOSS OF CONTACT
WITH REALITY (MINI – PSYCHOTIC
EPISODES)
– OFTEN COMORBID WITH MOOD
DISORDER
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 DEFENSE MECHANISM:
– DENIAL
– DISPLACEMENT
– SPLITTING
– POOR EGO FUNCTIONING

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TYPICAL PATIENT PRESENTATION

A 39 – YEAR – OLD FEMALE PATIENT

TELLS YOU ON HER SECOND VISIT
THAT SHE IS IN LOVE WITH YOU.
WHEN YOU REFER HER TO ANOTHER
PRACTITIONER, SHE ATTEMPTS
SUICIDE

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 AVOIDANT PERSONALITY
DISORDER
 THESE PATIENTS ARE:
– SHY
– SENITIVE TO REJECTION
– SOCIALLY WITHDRAWN
– HAS INFERIORITY COMPLEX
 DEFENSE MECHANISM:
– AVOIDANCE
– REGRESSION

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 Problems:

– SOCIAL PHOBIA
– DEPENDENT PD
– SCHIZOID PD

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TYPICAL PATIENT PRESENTATION

A 40 YEAR – OLD WOMAN WHO

LIVES ALONE SEEMS TENSE AND
FEARFUL. SHE TELLS YOU THAT SHE
WOULD LIKE TO HAVE FRIENDS BUT
IS AFRAID THAT PEOPLE WILL NOT
LIKE HER.

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OBSESSIVE – COMPULSIVE
PERSONALITY DISORDER
 THESE PATIENTS ARE:
– PERFECTIONISTIC
– ORDERLY
– STUBBORN
– INDECISIVE
 DEFENSE MECHANISM
– ISOLATION OF AFFECT
– RATIONALIZATION
– INTELLECTUALIZATION
– UNDOING
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 Problems:
– OBSESSIVE – COMPULSIVE DISORDER

TYPICAL PATIENT PRESENTATION

A 32 YEAR – OLD MALE PATIENT TELLS

YOU THAT HIS FOURTH ROOMMATE HAS
JUST MOVED OUT BECAUSE THE PATIENT
MAKES UNREASONABLE RULES AND
SCHEDULE CONCERNING THE CARE OF
THE APARTMENT

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DEPENDENT PERSONALITY
DISORDER
 THESE PATIENTS ARE:
– LACKS SELF – CONFIDENCE
– LETS OTHERS ASSUME THEIR
RESPONSIBILITIES

 DEFENSE MECHANISM
– REGRESSION
– AVOIDANCE

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 Problems:
– DEPRESSION

TYPICAL PATIENT PRESENTATION

A 30 YEAR – OLD FEMALE PATIENT

CALLS YOUR OFFICE FREQUENTLY TO
ASK YOUR ADVICE ABOUT OBVIOUS,
MINOR MEDICAL PROBLEMS

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 PASSIVE – AGGRESSIVE
PERSONALITY DISORDER
 THESE PATIENTS ARE:
– STUBBORN
– INEFFICIENT
– PROCASTINATES
– SEEMS COMPIANT BUT ARE DEFIANT
– NO LONGER A DSM IV DIAGNOSIS

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TYPICAL PATIENT PRESENTATION

TWO WEEKS AFTER YOUR 40 YEAR –

OLD MALE PATIENT AGREES THAT
HE NEEDS TO LOSE 10 POUNDS AND
YOU SPEND TIME DESCRIBING AN
APPROPRIATE DIET, HE HAS GAINED
2 POUNDS AND TELLS YOU THAT HE
DID NOT YET “GET A CHANCE” TO
BUY THE NECESSARY DIET.
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