PERSONALITY

DISORDERS

AMAN. D (Bsc PSYCHIATRY)

09/07/2021 1
 DEFENITION

personality disorder: is an enduring pattern of

inner experience and behavior that deviates
markedly from the expectations of the
individual's culture.
 pervasive and inflexible

has an onset in adolescence or early

adulthood
is stable over time, and
leads to distress or impairment.
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 Cont…
o Personality disorders are common and
chronic.
o They occur in 10 to 20 percent of the
general population and
o their duration is expressed in decades

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 Cont…
o personality disorder symptoms are ego
syntonic (i.e., acceptable to the ego/it creates
no distress for them even though it may
adversely affect others, as opposed to ego
dystonic) and alloplastic (i.e. adapt by trying
to alter the external environment rather than
themselves)
o Persons with personality disorders do not feel
anxiety about their maladaptive behavior.
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 classification
Based on descriptive similarities; the
personality disorders are grouped into
three clusters:-
Cluster A (odd or eccentric)
1) paranoid
2) schizoid
3) Schizotypal
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 Cont…
Cluster B (dramatic, emotional, or erratic)
1) Antisocial
2) Borderline
3) Histrionic and
4) Narcissistic

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 Cont…
Cluster C (anxious or fearful)
1) Avoidant
2) Dependent and
3) Obsessive compulsive
 individuals frequently present
with co-occurring personality
disorders from different clusters.
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 Prevalence estimation
 prevalence is different for each clusters:-
Cluster A=5.7%
Cluster B=1.5%
Cluster C=6.0%

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 ETIOLOGY

1.Genetic Factors
The concordance for personality
disorders among monozygotic twins was
several times than that of dizygotic twins
Cluster A personality disorders are more
common in the biological relatives of
patients with schizophrenia

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 Etiology Cont…
More relatives with schizotypal
personality disorder occur in the family
histories of persons with schizophrenia
Less correlation exists between paranoid
or schizoid personality disorder and
schizophrenia.

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 Cont…
Cluster B personality disorders:-
Antisocial personality disorder is associated
with alcohol use disorders
Borderline personality disorder is
associated with depression
strong association is found between
histrionic personality disorder and
somatization disorder
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 Cont…
Cluster C personality disorders:-
Avoidant personality disorder=high
anxiety levels
Obsessive-compulsive traits are more
common in monozygotic twins than in
dizygotic twins and show some signs
associated with depression

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 Cont…
2. Biological Factors
Hormones
High levels of testosterone, 17-estradiol,
and estrone in a persons who exhibit
impulsive traits
In non-human primates, androgens
increase the likelihood of aggression and
sexual behavior
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 Cont…
Platelet Monoamine Oxidase
Persons with low platelet MAO levels
report spending more time in social
activities than those with high platelet
MAO levels
Low platelet MAO levels have also been
noted in some patients with schizotypal
disorders
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 Cont…
Neurotransmitters
Studies of personality traits and the
dopaminergic and serotonergic systems
indicate an arousal activating function for
these neurotransmitters
Raising serotonin levels with
serotonergic agents can produce
dramatic changes in some character
traits of personality
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 Cont…
Electrophysiology
slow-wave activity on EEGs occur in some
patients with personality disorders, most
commonly antisocial and borderline
types

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 Cont…
3.Psychoanalytic Factors
Sigmund Freud
personality traits are related to a fixation at one
psychosexual stage of development
For example
those with an oral character are passive and
dependent because they are fixated at the oral
stage, when the dependence on others for food is
prominent
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 Cont…
Wilhelm Reich
coined the term character armor to
describe persons’ characteristic defensive
styles for protecting themselves from
internal impulses and from interpersonal
anxiety in significant relationships
Each personality disorder has a cluster of
defenses
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 Cont…
When defenses work effectively, persons
with personality disorders master feelings
of anxiety, depression, anger, shame,
guilt, and other affects
They may also be reluctant to engage in a
treatment process; because their
defenses are important in controlling
unpleasant affects
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 Cont…
In addition to characteristic defenses in
personality disorders, another central
feature is internal object relations which
internalized during development as
particular patterns of the self in relation
to others

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 Common Defense Mechanisms in PDs

o Is the unconscious mental processes that

the ego uses to resolve conflicts among
the four lodestars of the inner life:-
1.instinct (wish or need)
2.reality
3.important persons and
4.conscience

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 Defense mechanisms cont…
The following are common defense
mechanisms used in personality disorders
1. FANTASY
persons who labeled schizoid—those who
are eccentric, lonely, or frightened—seek
solace and satisfaction within themselves
by creating imaginary lives, especially
imaginary friends
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 Cont…
2. DISSOCIATION
replacement of unpleasant affects with
pleasant ones
Persons who frequently dissociate are
often seen as dramatizing and emotionally
shallow
they may be labeled histrionic personalities

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 Cont…
3.ISOLATION
 characteristic of controlled & orderly persons
 Often labeled obsessive-compulsive
personalities
 such patients respond well to precise,
systematic, and rational explanations and
value efficiency, cleanliness, and punctuality

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 Cont…
4.PROJECTION
patients attribute their own
unacknowledged feelings to others
excessive faultfinding and sensitivity to
criticism

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 cont…
5.SPLITTING
 persons toward whom patients’ feelings are,
or have been, ambivalent are divided into
totally good and bad.
For example,
=>in an inpatient setting, a patient may idealize
some staff members and uniformly disparage
others

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 Cont…
6.PASSIVE AGGRESSION
turning their anger against themselves
(the phenomenon called masochism in
psychoanalytic terms)
7.ACTING OUT
patients directly express unconscious
wishes or conflicts through action

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 General criteria for Personality Disorders

A. An enduring pattern of inner experience and

behavior that 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).

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 Criteria cont…
2. Affectivity (i.e., the range, intensity, lability,
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.

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 Cont…
C. The enduring pattern leads to clinically
significant distress or impairment in social,
occupational, or other important areas of
functioning.
D. The pattern is stable and long duration, and
Its onset can be traced back at least to
adolescence or early adulthood

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 Cont…
E. The enduring pattern is not better explained
as a manifestation or consequence of another
mental disorder.
F. The enduring pattern is not attributable to the
physiological effects of a substance (e.g., a
drug of abuse, a medication) or another
medical condition (e.g., head trauma).

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 Cluster A personality disorders
1.PARANOID PERSONALITY DISORDER
A. Epidemiology
 2 to 4 percent of the general population
 Relatives of patients with schizophrenia show a higher
incidence of paranoid personality disorder than general
population
 relationship with delusional disorder, persecutory type
 commonly diagnosed in men than in women
 believed to be higher among minority groups, immigrants,
and persons who are deaf than it is in the general
population
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 Cluster A cont…
B. Clinical Features
Excessive suspiciousness and distrust of
others (hallmarks); interpret actions of
others as deliberately demeaning,
malevolent, threatening, exploiting, or
deceiving, the tendency begins by early
adulthood and appears in a variety of
contexts
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 Cont…
Frequently dispute, without any
justification, friends’ or associates’
loyalty or trustworthiness
Such persons are often pathologically
jealous and, for no reason, question the
fidelity of their spouses or sexual
partners

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 Cont…
They refuse responsibility for their own
feelings and assign responsibility to
others
They are often hostile, irritable, and
angry
Externalize their own emotions and use
the defense of projection
Ideas of reference and logically defended
illusions are common
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 Cont…
Affectively restricted and appear to be
unemotional
They pride themselves on being rational
and objective
They lack warmth and are impressed
with, and pay close attention to, power
and rank

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 Cont…
C. Diagnosis
o On psychiatric examination, patients with
paranoid personality disorder may be
formal in manner and act baffled about
having to seek psychiatric help
o Muscular tension, inability to relax, and a
need to scan the environment for clues
may be evident
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 Cont…
o patient’s manner is often humorless and
serious
o Although some premises of their
arguments may be false, their speech is
goal directed and logical
o Their thought content shows evidence of
projection, prejudice, and occasional ideas
of reference
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 D. DSM-5 Diagnostic Criteria
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.

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 Cont…
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.

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 Cont…
5. Persistently bears grudges (i.e., is unforgiving
of insults, injuries, or slights).
6. Perceives attacks on his or her character or
reputation that are not apparent to others and
is quick to react angrily or to counter-attack.
7. Has recurrent suspicions, without justification,
regarding fidelity of spouse or sexual partner.

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 Cont…
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).”
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 E. Differential Diagnosis
1.Delusional disorder=>differentiated from
paranoid PD by presence of fixed
delusions
2. paranoid schizophrenia=> differentiated
by presence of hallucination or formal
thought disorder

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 Cont…
3.borderline personality disorder=>
differentiated by capable of overly
involved in relationships with others.
4.Antisocial personality disorder=>
differentiated by lack of the long history
of antisocial behavior in paranoid
personality disorder

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 Cont…
5.schizoid personality disorder=> persons
with this disorder are withdrawn and
aloof and do not have paranoid ideation

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 F. Course and Prognosis

 No adequate, systematic long-term studies

 In some, paranoid personality disorder is
lifelong
 in others it is a harbinger of schizophrenia
 Still in others, paranoid traits give way to
reaction formation, appropriate concern with
morality, and altruistic concerns as they
mature or as stress diminishes.

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 Cont…
In general, however, those with paranoid
personality disorder have life-long
problems working and living with others
Occupational and marital problems are
common

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 G. Treatment
Psychotherapy
treatment of choice(Individual psychotherapy)
Patients who are paranoid are profoundly
frightened when they feel that those trying to
help them are weak and helpless; therefore,
therapists should never offer to take control
unless they are willing and able to do so

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 Cont…
Pharmacotherapy
useful in dealing with agitation and
anxiety
antianxiety agent such as diazepam and
antipsychotic such as haloperidol in small
dosages and for brief periods to manage
severe agitation may be used

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 Cont…
2. SCHIZOID PERSONALITY DISORDER
A. Epidemiology
 Prevalence not clearly established (5 percent in
general population?)
 sex ratio of the disorder is unknown (some studies
report male-to-female=2-to-1?)
 Persons with this disorder tend to gravitate toward
solitary jobs that involve little or no contact with
others (prefer night work to day work)

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 Cont…
B. Clinical Features
 lifelong pattern of social withdrawal
 Persons with schizoid personality disorder seem
to be cold and aloof
 They appear quiet, distant, seclusive, and
unsociable
 They reflect solitary interests and success at
noncompetitive, lonely jobs that others find
difficult to tolerate
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 Cont…
 Their sexual lives may exist exclusively in
fantasy
 Men may not marry because they are unable
to achieve intimacy; women may passively
agree to marry an aggressive man who wants
the marriage
 They usually reveal a lifelong inability to
express anger directly

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 Cont…
 They invest energy in nonhuman interests,
such as mathematics, philosophical
movements and astronomy; and they may be
very attached to animals
 Despite these, they have a normal capacity to
recognize reality and sometimes give to the
world genuinely original, creative ideas

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 Cont…
C. Diagnosis
patients with schizoid personality disorder
may appear ill at ease on an initial psychiatric
examination
They rarely tolerate eye contact and they are
eager for the interview to end
Their affect may be constricted, aloof, or
inappropriately serious

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 Cont…
Their speech is goal directed
They are likely to give short answers to
questions and to avoid spontaneous
conversation
Their sensorium is intact
Their memory functions well, and
Their proverb interpretations are abstract

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 D.DSM-5 Diagnostic Criteria
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.

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 Cont…
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

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 Cont…
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).”
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 E. Differential Diagnosis
1) Schizophrenia
2) Delusional disorder
3) Affective disorder with psychotic features
Þ Schizoid personality disorder is distinguished
from the above conditions based on periods
with positive psychotic symptoms, such as
delusions and hallucinations

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 Cont…
4) paranoid personality disorder
=>Distinguished from schizoid personality
disorder by exhibiting:-
 more social engagement
history of aggressive verbal behavior and
greater tendency to project their feelings
onto others

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 Cont…
5) Obsessive-compulsive personality disorder
=>Distinguished from schizoid personality
disorder by:-
history of past object relations and
they do not engage as much in autistic
behavior

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 Cont…
6) Schizotypal personality disorder.
=>patient who is schizotypal is more
similar to a patient with
schizophrenia in oddities of
perception, thought, behavior, and
communication

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 Cont…
7) Avoidant personality disorder
=>Patients with avoidant personality
disorder are isolated but strongly
wish to participate in activities, a
characteristic absent in those with
schizoid personality disorder

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 Cont…
8) Autistic disorder
9) Asperger’s syndrome
=>more severely impaired social
interactions and stereotypical
behaviors and interests in schizoid
personality disorder than in these
two disorders
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 F. Course and Prognosis
Onset usually occurs in early
childhood or adolescence
long lasting but not necessarily
lifelong
proportion of patients who incur
schizophrenia is unknown

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 G. Treatment
Psychotherapy
o similar to that of those with paranoid
personality disorder
o Can involve in group therapy
o may be silent for long periods
o the patients should be protected
against aggressive attack by group members
to be silent
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 Cont…
Pharmacotherapy
small dosages of antipsychotics,
antidepressants, and psycho-stimulants
has benefitted some patients
Serotonergic agents may make patients
less sensitive to rejection
Benzodiazepines may help diminish
interpersonal anxiety
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 Cont…
3.SCHIZOTYPAL PERSONALITY DISORDER
A. Epidemiology
 occurs in about 3 percent of the population
 the sex ratio is unknown; however, it is
frequently diagnosed in females with fragile X
Syndrome
 DSM-5 suggests the disorder may be slightly
more common in males
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 Cont…
greater association of cases exists among
the biological relatives of patients with
schizophrenia
higher incidence among monozygotic
twins than among dizygotic twins (33
percent vs. 4 percent in one study)

09/07/2021 69
 Cont…
B. Clinical Features
• Persons with schizotypal personality
disorder are strikingly odd or strange
• Magical thinking, peculiar notions, ideas of
reference, illusions, and derealization are
part of a schizotypal person’s everyday world
• They exhibit disturbed thinking and
communication
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 Cont…
• Although frank thought disorder is
absent, their speech may be distinctive
or peculiar, may have meaning only to
them, and often needs interpretation
• These patients may be superstitious or
claim powers of clairvoyance and may
believe that they have other special
powers of thought and insight
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 Cont…
• Their inner world may be 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 all are the same
• In severe cases of the disorder the patient
may exhibit anhedonia and severe depression

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 Cont…
C. Diagnosis
diagnosed on the basis of the patients’
peculiarities of thinking, behavior, and
appearance
Taking a history may be difficult because
of the patients’ unusual way of
communication

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 D. DSM-5 Diagnostic Criteria
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:
09/07/2021 74
 Cont…
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.

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 Cont…
4. Odd thinking and speech (e.g., vague,
circumstantial, metaphorical, over elaborate, 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.
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 Cont…
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.
09/07/2021 77
 Cont…
• Note: If criteria are met prior to the onset of
schizophrenia, add “premorbid,” e.g.,
“schizotypal personality disorder (premorbid).”

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 E. Differential Diagnosis
1. schizoid personality disorder
2. Avoidant personality disorder
Þ distinguished from these disorders by:-
the presence of oddities in their
behavior, thinking, perception, and
communication and
perhaps by a clear family history of
schizophrenia
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 Cont…
3. schizophrenia
 Schizotypal PD distinguished from schizophrenia by their
absence of psychosis (if psychotic symptoms do appear,
they are brief and fragmentary)
4.Borderline personality disorder
 This mostly occur with Schizotypal PD
5.Paranoid personality disorder
 characterized by suspiciousness but lack the odd
behavior of patients with schizotypal personality
disorder
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 F. Course and Prognosis
 Current clinical thinking points as the schizotype
is the premorbid personality of the patient with
schizophrenia
 Some maintain a stable schizotypal personality
throughout their lives and marry and work,
despite their oddities
 A long-term of one study reported that 10
percent of those with schizotypal personality
disorder eventually committed suicide
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 G. Treatment
Psychotherapy
The same to the previous other
personality disorders
Clinician should pay attention to peculiar
patterns of thinking and strange religious
practices that some of these patients
involved

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 Cont…
Pharmacotherapy
Antipsychotic=>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 the personality
is present
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 Cluster B personality disorders
1. ANTISOCIAL PERSONALITY DISORDER
A. Epidemiology
12-month prevalence rates are between
0.2 and 3 percent according to DSM-5
More common in poor urban areas and
among mobile residents of these areas

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 Cont…
 The highest prevalence is found among the
most severe samples of men with alcohol use
disorder (over 70%) and in prison populations
(which may be as high as 75%)
 It is much more common in males than in
females
 Boys with the disorder come from larger
families than girls with the disorder

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 Cont…
The onset of the disorder is before the
age of 15 years
Girls usually have symptoms before
puberty and boys even earlier
The disorder is five times more common
among first-degree relatives of men with
the disorder

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 B. Clinical Features
Inability to conform to the social norms
that ordinarily govern many aspects of a
person’s adolescent and adult behavior
Although characterized by continual
antisocial or criminal acts, the disorder is
not synonymous with criminality

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 Cont…
Patients can often seem to be normal
and even charming and ingratiating
Lying, truancy, running away from home,
thefts, fights, substance abuse, and
illegal activities are typical experiences
that reported as beginning in childhood

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 Cont…
They often impress opposite-sex clinicians
with the colorful, seductive aspects of their
personalities, but same-sex clinicians may
regard them as manipulative and demanding
They exhibit no anxiety or depression
(because the symptoms are acceptable to
them) although suicide threats and somatic
preoccupations may be common

09/07/2021 89
 Cont…
 Complete absence of delusions and other
signs of irrational thinking
 They have sense of reality testing and often
impress observers as having good verbal
intelligence
 They are highly representative of so-called con
men

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 Cont…
 They do not tell the truth and cannot be
trusted to carry out any task or adhere to any
conventional standard of morality
 Promiscuity, spousal abuse, child abuse, and
drunk driving are common events in their lives
 They lack remorse for these actions; that is,
they appear to lack a conscience

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 C. Diagnosis
o They can fool even the most experienced
clinicians
o In an interview, patients can appear
composed and credible, but beneath the
veneer lurks tension, hostility, irritability,
and rage appear,(the term called the
mask of sanity)

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 Cont…
o A diagnostic workup should include a
thorough neurological examination, because
patients often show abnormal EEG results and
soft neurological signs suggesting minimal
brain damage in childhood

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 D. DSM-5 Diagnostic Criteria
A. A pervasive pattern of disregard for and
violation of the rights of others, occurring
since age 15 years, as indicated by three (or
more) of the following:
1. Failure to conform to social norms with
respect to lawful behaviors, as indicated by
repeatedly performing acts that are grounds
for arrest.

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 Cont…
2. Deceitfulness, as indicated by repeated lying,
use of aliases, or conning others for personal
profit or pleasure.
3. Impulsivity or failure to plan ahead.
4. Irritability and aggressiveness, as indicated by
repeated physical fights or assaults.
5. Reckless disregard for safety of self or others

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 Cont…
6. Consistent irresponsibility, as indicated by
repeated failure to sustain consistent work
behavior or honor financial obligations.
7. Lack of remorse, as indicated by being
indifferent to or rationalizing having hurt,
mistreated, or stolen from another.
B. The individual is at least age 18 years.

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 Cont…
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.

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 E. Differential Diagnosis
1.Illegal behavior/criminal act
=>antisocial personality disorder involves many
areas of a person’s life
2. substance abuse
=>difficult to differentiate
=>When both begin in childhood and continue
into adult life, both disorders should be
diagnosed
09/07/2021 98
 Cont…
however, when the antisocial behavior is
clearly secondary to premorbid alcohol abuse
or other substance abuse, the diagnosis of
antisocial personality disorder is not warranted
the diagnosis of antisocial personality disorder
is not warranted when intellectual disability,
schizophrenia, or mania can explain the
symptoms

09/07/2021 99
 F. Course and Prognosis
 Runs an unremitting course, with the height of
antisocial behavior usually occurring in late
adolescence.
 The prognosis varies.
 Some reports indicate that symptoms decrease as
persons grow older.
 Many patients have somatization disorder and multiple
physical complaints.
 Depressive disorders, alcohol use disorders, and other
substance abuse are common
09/07/2021 100
 G. Treatment
Psychotherapy
• self-help groups have been more useful than jails
in alleviating the disorder
Pharmacotherapy
 used to deal with symptoms such as anxiety, rage,
and depression
 If a patient shows evidence of attention-
deficit/hyperactivity disorder, psycho stimulants
such as methylphenidate may be useful
09/07/2021 101
 Cont…
 Attempts have been made to alter
catecholamine metabolism with drugs and to
control impulsive behavior with antiepileptic
drugs, for example, carbamazepine (Tegretol)
or valproate (Depakote), especially if
abnormal waveforms are noted on an EEG

09/07/2021 102
2.BORDERLINE PERSONALITY DISORDER

A. Epidemiology
 No definitive prevalence studies are available
 Thought to be present in about 1 to 2 percent of
the population and is twice as common in
women as in men
 Increased prevalence of major depressive
disorder, alcohol use disorders, and substance
abuse is found in first-degree relatives of
persons
09/07/2021 103
 B. Clinical Features
 They stand on the border between neurosis
and psychosis
 They are characterized by extraordinarily
unstable affect, mood, behavior, object
relations, and self-image
 They almost always appear to be in a state of
crisis
 Mood swings are common

09/07/2021 104
 Cont…
 Patients can be argumentative at one moment,
depressed the next, and later complain of
having no feelings
 Patients can have short lived psychotic episodes
(so-called micro psychotic episodes)
 The behavior of patients with borderline
personality disorder is highly unpredictable, and
their achievements are rarely at the level of
their abilities.
09/07/2021 105
 Cont…
 The painful nature of their lives is reflected in
repetitive self-destructive acts
 Such patients may slash their wrists and
perform other self-mutilations to elicit help
from others, to express anger, or to numb
themselves to overwhelming affect
 They feel both dependent and hostile

09/07/2021 106
 Cont…
They cannot tolerate being alone and
even they accept a stranger as a friend in
fear of being alone for short period of
time
They often complain about chronic
feelings of emptiness and boredom and
the lack of a consistent sense of identity
(identity diffusion)
09/07/2021 107
 Cont…
 They use primitive defense mechanism called
projective identification in which intolerable
aspects of the self are projected onto another
and the other person is induced to play the
projected role, and the two persons act in
unison
 They distort their relationships by considering
each person to be either all good or all bad.

09/07/2021 108
 C. Diagnosis
Diagnosis can made by early adulthood
Biological studies may aid in the
diagnosis
Some patients show shortened REM
latency and sleep continuity disturbances

09/07/2021 109
 E. DSM-5 Diagnostic Criteria
A pervasive pattern of instability of
interpersonal relationships, self-image,
and affects, and marked impulsivity,
beginning by early adulthood and
present in a variety of contexts, as
indicated by five (or more) of the
following:

09/07/2021 110
 Cont…
1. Frantic efforts to avoid real or imagined
abandonment. (Note: Do not include suicidal
or self-mutilating behavior covered in Criterion
5.)
2. A pattern of unstable and intense
interpersonal relationships characterized by
alternating between extremes of idealization
and devaluation.

09/07/2021 111
 Cont…
3. Identity disturbance: markedly and
persistently unstable self-image or sense of
self.
4. Impulsivity in at least two areas that are
potentially self-damaging (e.g., spending, sex,
substance abuse, reckless driving, binge
eating). (Note: Do not include suicidal or self
mutilating behavior covered in Criterion 5.)

09/07/2021 112
 Cont…
5. Recurrent suicidal behavior, gestures, or
threats, or self-mutilating behavior.
6. Affective instability due to a marked
reactivity of mood (e.g., intense episodic
dysphoria, irritability, or anxiety usually
lasting a few hours and only rarely more
than a few days).

09/07/2021 113
 Cont…
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty
controlling anger (e.g., frequent displays
of temper, constant anger, recurrent
physical fights).
9. Transient, stress-related paranoid
ideation or severe dissociative symptoms

09/07/2021 114
 E. Differential Diagnosis
1.Schizophrenia
=>patient with borderline personality lacks
prolonged psychotic episodes, thought
disorder, and other classic schizophrenic signs
2.Schizotypal personality disorder
=>show marked peculiarities of thinking, strange
ideation, and recurrent ideas of reference

09/07/2021 115
 Cont…
3.paranoid personality disorder
=>patients with this disorder are marked
by extreme suspiciousness, but patients
with borderline personality disorder
generally have chronic feelings of
emptiness and short lived psychotic
episodes

09/07/2021 116
 F. Course and Prognosis
Course is fairly stable; patients change
little over time.
Longitudinal studies show no progression
toward schizophrenia, but high incidence
of major depressive disorder episodes.
The diagnosis is usually made before the
age of 40 years

09/07/2021 117
 G. Treatment
Psychotherapy
 treatment of choice even though it is difficult
for them and therapist
 Projective identification and splitting defense
mechanisms are the main causes of difficulty
in these patients
 behavior therapy is needed to control
patients’ impulses and angry

09/07/2021 118
 Cont…
Social skills training, especially with
videotape playback, helps enable
patients to see how their actions affect
others and thereby improve their
interpersonal behavior
psychotherapy can be given on both an
individual and a group basis

09/07/2021 119
 Group seminar
Some types of psychotherapy used in personality disorders

1) DIALECTICAL BEHAVIOR THERAPY

2) MENTALIZATION-BASED TREATMENT

3) TRANSFERENCE-FOCUSED PSYCHOTHERAPY

4) FREE ASSOCIATION

5) COUNTER-TRANSFERENCE
09/07/2021 120
 Cont…
Pharmacotherapy
• Antipsychotics have been used to control
anger, hostility, and brief psychotic
episodes
• Antidepressants improve the depressed
mood common. MAOIs have successfully
modulated impulsive behavior in some
patients.
09/07/2021 121
 Cont…
• Benzodiazepines, particularly alprazolam, help
anxiety and depression, but some patients
show a disinhibition with this class of drugs.
• Anticonvulsants, such as carbamazepine, may
improve global functioning for some patients.
• Serotonergic agents such as selective
serotonin reuptake inhibitors (SSRIs) have
been helpful in some cases

09/07/2021 122
 3.HISTRIONIC PERSONALITY DISORDER

A. Epidemiology
o about 1 to 3 percent in general population
o rates of about 10 to 15 percent have been
reported in inpatient and outpatient mental
health settings
o more frequent in women than in men
o some association with somatization disorder
and alcohol use disorders
09/07/2021 123
 B. Clinical Features

 High degree of attention-seeking behavior

 They tend to exaggerate their thoughts and
feelings and make everything sound more
important than it really is.
 They display temper tantrums, tears, and
accusations when they are not the center of
attention or are not receiving praise or
approval

09/07/2021 124
 Cont…
 Seductive behavior is common in both sexes
(sexual fantasies are common)
 They may have a psychosexual dysfunction;
women may be anorgasmic, and men may be
impotent
 They may act on their sexual impulses to
reassure themselves that they are attractive to
the other sex

09/07/2021 125
 Cont…
 Their relationships tend to be superficial
 Their strong dependence needs make them
overly trusting and gullible
 Repression and dissociation are common
defenses they use
 They are unaware of their true feelings and
cannot explain their motivations.
 Under stress, reality testing easily becomes
impaired
09/07/2021 126
 C. Diagnosis

 In interviews, they are generally

cooperative and eager to give a detailed
history.
 Gestures and dramatic punctuation in
their conversations are common
 They may make frequent slips of the
tongue, and their language is colorful

09/07/2021 127
 D. DSM-5 Diagnostic Criteria

A pervasive pattern of excessive

emotionality and attention seeking,
beginning by early adulthood
and present in a variety of contexts, as
indicated by five (or more) of the
following:
1. Is uncomfortable in situations in which
he or she is not the center of attention
09/07/2021 128
 Cont…
2.Interaction with others is often
characterized by inappropriate sexually
seductive or provocative behavior.
3.Displays rapidly shifting and shallow
expression of emotions.
4.Consistently uses physical appearance to
draw attention to self.

09/07/2021 129
 Cont…
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

09/07/2021 130
 E. Differential Diagnosis

1.borderline personality
 Distinguishing is difficult b/n two, but in borderline
personality disorder, suicide attempts, identity diffusion, and
brief psychotic episodes are more likely
2.Somatization disorder
 may occur in conjunction with histrionic personality disorder.
3.brief psychotic disorder
4.dissociative disorders
 These both may warrant a coexisting diagnosis of histrionic
personality disorder

09/07/2021 131
 F. Course and Prognosis

With age, persons with histrionic

personality disorder show fewer
symptoms
Persons with this disorder are sensation
seekers, and
They may get into trouble with the law,
abuse substances, and act promiscuously

09/07/2021 132
 G. Treatment

Psychotherapy
 They often unaware of their own real feelings;
clarification of their inner feelings is an
important therapeutic process
 Psychoanalytically oriented psychotherapy,
whether group or individual, is probably the
treatment of choice for histrionic personality
disorder

09/07/2021 133
 Cont…
Pharmacotherapy
=>can be adjunctive when symptoms are
targeted
for example:-
o antidepressants for depression and somatic
complaints,
o antianxiety agents for anxiety, and
o antipsychotics for derealization and illusions
09/07/2021 134
 4.NARCISSISTIC PERSONALITY DISORDER

A. Epidemiology
• Prevalence ranges from less than 1 to 6
percent in community
• offspring of such patients may have a
higher than usual risk for developing the
disorder themselves

09/07/2021 135
 B. Clinical Features
 Persons with this disorder characterized by a
heightened sense of self-importance, lack of
empathy, and grandiose feelings of
uniqueness
 Underneath, however, their self-esteem is
fragile and vulnerable to even minor criticism
 they consider themselves special and expect
special treatment

09/07/2021 136
 C. DSM-5 Diagnostic Criteria

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 (e.g.,
exaggerates achievements and talents,
expects to be recognized as superior without
commensurate achievements).
09/07/2021 137
 Cont…
2.Is preoccupied with fantasies of 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 or high-status
people (or institutions).
4. Requires excessive admiration.

09/07/2021 138
 Cont…
5.Has a sense of entitlement (i.e.,
unreasonable expectations of especially
favorable treatment or automatic
compliance with his or her expectations).
6. Is interpersonally exploitative (i.e., takes
advantage of others to achieve his or her
own ends).

09/07/2021 139
 Cont…
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.

09/07/2021 140
 D. Differential Diagnosis
1.Borderline personality disorder
-> difficult to identify
->Patients with narcissistic personality
disorder have less anxiety than those
with borderline personality disorder;
their lives tend to be less chaotic, and
they are less likely to attempt suicide

09/07/2021 141
 Cont…
2.Antisocial personality disorder
=>have a history of impulsive behavior, often
associated with alcohol or other substance
abuse, which frequently gets them into trouble
with the law
3.Histrionic personality disorder
=>show features of exhibitionism and interpersonal
manipulativeness that resemble those of patients
with narcissistic personality disorder
09/07/2021 142
 E. Course and Prognosis

 Narcissistic personality disorder is chronic and

difficult to treat
 Aging is handled poorly
F. Treatment
Psychotherapy
• the treatment of narcissistic personality disorder is
difficult
• using psychoanalytic approaches to effect change
• Some clinicians advocate group therapy
09/07/2021 143
 Cont…
Pharmacotherapy
 Lithium (Eskalith) has been used with patients
whose clinical picture includes mood swings
 Because patients with narcissistic personality
disorder tolerate rejection poorly and are
susceptible to depression, antidepressants,
especially serotonergic drugs, may also be of
use

09/07/2021 144
 Cluster C personality disorders
1.AVOIDANT PERSONALITY DISORDER
A. Epidemiology
• prevalence of the disorder is suggested
to be about 2 to 3 percent of the general
population according to DSM-5.
• No information is available on sex ratio
or familial pattern

09/07/2021 145
 B. Clinical Features

 Persons with avoidant personality disorder show

extreme sensitivity to rejection and may lead socially
withdrawn lives.
 Although shy, they are not asocial and show a great
desire for companionship
 Such persons are commonly described as having an
inferiority complex.
 Hypersensitivity to rejection by others is the central
clinical feature of avoidant personality disorder

09/07/2021 146
 Cont…
 patients’ main personality trait is timidity
 When talking with someone, they express
uncertainty, show a lack of self-confidence, and
may speak in a self-effacing manner
 They generally unwilling to enter relationships
unless they are given an unusually strong
guarantee of uncritical acceptance;
Consequently, they often have no close friends
or confidants
09/07/2021 147
 C. Diagnosis

• In clinical interviews, patients’ most

striking aspect is anxiety about talking
with an interviewer.
• Their nervous and tense manner appears
to wax and wane with their perception of
whether an interviewer likes them

09/07/2021 148
 D. DSM-5 Diagnostic Criteria

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.

09/07/2021 149
 Cont…
2.Is unwilling to get involved 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

09/07/2021 150
 Cont…
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
09/07/2021 151
 E. Differential Diagnosis

1.Schizoid personality disorder

 They want to be alone unlike Patients with
avoidant personality disorder which desire
social interaction
2.borderline personality disorder
3.histrionic personality disorder
=>these two are demanding, irritable, or
unpredictable unlike avoidant PD
09/07/2021 152
 cont…
4.dependent personality disorder
 Both are almost similar, but patients with
dependent personality disorder are presumed
to have a greater fear of being abandoned or
unloved than those with avoidant personality
disorder

09/07/2021 153
 F. Course and Prognosis

• Many persons with avoidant personality

disorder are able to function in a
protected environment
• Some marry, have children, and live their
lives surrounded only by family members

09/07/2021 154
 G. Treatment

Psychotherapy
• Group therapy may help patients understand
how their sensitivity to rejection affects them
and others
Pharmacotherapy
• Has been used to manage anxiety and
depression when they are associated with the
disorder

09/07/2021 155
 2.DEPENDENT PERSONALITY DISORDER

A. Epidemiology
 more common in women than in men
 estimated prevalence is 0.6 percent
 more common in young children than in older
ones.
 Persons with chronic physical illness in
childhood may be most susceptible to the
disorder
09/07/2021 156
 B. Clinical Features

 subordinate their own needs to those of others,

get others to assume responsibility for major
areas of their lives
 lack self confidence, and may experience
intense discomfort when alone for more than a
brief period.
 characterized by dependence, pessimism, fear
of sexuality, self-doubt, passivity, suggestibility,
and lack of perseverance
09/07/2021 157
 Cont…
 characterized by a pervasive pattern of
dependent and submissive behavior.
 they cannot make decisions without an
excessive amount of advice and reassurance
from others.
 they avoid positions of responsibility and
become anxious if asked to assume a
leadership role

09/07/2021 158
 C. Diagnosis

In interviews, patients appear compliant.

They try to cooperate, welcome specific
questions, and look for guidance

09/07/2021 159
 D. DSM-5 Diagnostic Criteria

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
09/07/2021 160
 Cont…
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.
(Note: Do not include realistic fears of retribution.)
4. Has difficulty initiating projects or doing things on
his or her own (because of a lack of self-confidence
in judgment or abilities rather than a lack of
motivation or energy

09/07/2021 161
 Cont…
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 care for himself or
herself.
09/07/2021 162
 Cont…
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.

09/07/2021 163
 E. Differential Diagnosis

 Differential diagnosis is difficult since the traits of

dependence are found in many psychiatric
disorders
1.Histrionic personality disorder
2.Borderline personality disorder
 dependent personality disorder usually have a
long-term relationship with one person rather
than a series of persons unlike the above two
conditions
09/07/2021 164
 Cont…
3.Agoraphobia
these patients tend to have a high level
of overt anxiety or even panic in addition
to dependence behavior

09/07/2021 165
 F. Course and Prognosis

o Occupational functioning tends to be impaired

because of dependence
o Social relationships are limited to those on
whom they can depend
o They risk major depressive disorder if they
lose the person on whom they depend, but
with treatment, the prognosis is favorable

09/07/2021 166
 G. Treatment
Psychotherapy
=>The treatment is often successful.
 Insight-oriented therapies
 Behavioral therapy,
 assertiveness training,
 family therapy, and
 group therapy have
=>all have been used, with successful outcomes in
many cases
09/07/2021 167
 Cont…
Pharmacotherapy
o used to deal with specific symptoms, such as
anxiety and depression, which are common
associated features of dependent personality
disorder.
o Patients who experience panic attacks or who
have high levels of separation anxiety may be
helped by imipramine

09/07/2021 168
 3.OBSESSIVE-COMPULSIVE PERSONALITY
DISORDER
A. Epidemiology
 DSM-5 reports an estimated prevalence
ranging from 2 to 8 percent
 more common in men than in women and is
diagnosed most often in oldest siblings occurs
 more frequently in first-degree biological
relatives of persons with the disorder than in
the general population

09/07/2021 169
 B. Clinical Features

 characterized by emotional constriction, orderliness,

perseverance, stubbornness, and indecisiveness
 pervasive pattern of perfectionism and inflexibility
(essential features)
 preoccupied with rules, regulations, orderliness,
neatness, details, and the achievement of perfection
 they are formal and serious and often lack a sense of
humor

09/07/2021 170
 C. Diagnosis

o In interviews, patients are stiff, formal, and

rigid
o their affect is not blunted or flat but can be
described as constricted
o their mood is usually serious.
o their answers to questions are unusually detailed
o they use defense mechanisms like
rationalization, isolation, intellectualization,
reaction formation, and undoing
09/07/2021 171
 D. DSM-5 Diagnostic Criteria

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, lists, order,
organization, or schedules to the extent that the
major point of the activity is lost

09/07/2021 172
 Cont…
2.Shows perfectionism that interferes with task
completion (e.g., is unable to complete a
project because his or her own overly strict
standards are not met).
3.Is excessively devoted to work and productivity
to the exclusion of leisure activities and
friendships (not accounted for by obvious
economic necessity)

09/07/2021 173
 Cont…
4.Is over conscientious, scrupulous, and inflexible
about matters of morality, ethics, or values
(not accounted for by cultural or religious
identification)
5.Is unable to discard worn-out or worthless
objects even when they have no sentimental
value

09/07/2021 174
 Cont…
6. Is reluctant to delegate tasks or to 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

09/07/2021 175
 E. Differential Diagnosis

1.obsessive-compulsive disorder
F. Course and Prognosis
The course of obsessive-compulsive
personality disorder is variable and
unpredictable

09/07/2021 176
 G. Treatment

Psychotherapy
 Unlike patients with the other personality
disorders, those with obsessive-compulsive
personality disorder often aware of their
suffering, and they seek treatment on their own
 often long and complex, and counter-
transference problems are common
 Group therapy and behavior therapy occasionally
offer certain advantages
09/07/2021 177
Pharmacotherapy
 Clonazepam, benzodiazepine with
anticonvulsant use, has reduced symptoms in
patients with severe obsessive-compulsive
disorder
 Clomipramine and such serotonergic agents as
fluoxetine, usually at dosages of 60 to 80 mg a
day may be useful

09/07/2021 178
 OTHER SPECIFIED PERSONALITY DISORDER

1.Passive-Aggressive Personality
o Persons with passive-aggressive
personality are characterized by covert
obstructionism, procrastination,
stubbornness, and inefficiency.
o Such behavior is a manifestation of
passively expressed underlying aggression

09/07/2021 179
 Cont...
2.Depressive Personality
 Persons with depressive personality are
characterized by lifelong traits that fall
along the depressive spectrum.
 They are pessimistic, anhedonic, duty
bound, self-doubting, and chronically
unhappy

09/07/2021 180
 What do you see?

09/07/2021 181
 LOOKING IN-DEPTH OF THE PICTURE

1. A bold old person,

2. A person (blind?) with a stick,
3. A lady carrying grasses (?),
4. Gray haired person at the back,
5. Layers of stones (fence),
6. Doors,
7. Steps,
8. A Window,
9. A tube for water flowing,
10.‘OSTERIA’, written on the gate
09/07/2021 182
 ANY QUESTION??
?
?

09/07/2021 183