Personality disorders

For BSc psychiatry students

Set by: Girum Nakie (BSc, MSc)
girumnakie@gmail.com/Tell: 0918570170

01/03/2022 By Giruman 1
 Learning objectives

At the end of the course, the student will be able to:

 To understand definition of Personality,
 To identify Normal Versus Deviant Personality behavior

 To know the classification of Personality Disorders

 To identify the etiology of personality disorders
 To describe clinical features and its management

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 What is personality?
 Personality is the totality of emotional and behavioral
characteristics those are particular to a specific person and that
remain somewhat stable and predictable over time.
 Personality describes the innate and enduring characteristics of
an individual which shape their
 Attitudes
 Thoughts

 Behaviors in response to situations.

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 We all recognize, amongst people we know well, some who
manifest certain characteristics more than others:
 shyness
 Confidence

 Anger
 Generosity
 Sensitivity, and being pernickety

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 Personality is an individuals unique constellation of consistent
behavioral traits.
 A personality trait is a durable disposition to behave in a
particular way in a variety of situations.
 Personality can be positive or negative personality
o Positive personality like honest, friendly, cheerful, confidence,
accountable…
o Negative personality like impulsiveness, lay, arrogant ….

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 personality disorder

 personality disorder: is an enduring pattern of inner

experience and behavior that deviates markedly from the
expectations of the individual's culture.
 It is also

 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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 Over view of personality disorder
Personality disorders occur in 10 to 20 % of the general population.
Approximately 50 % of all psychiatric patients have a PD.
PD is also a predisposing factor for other psychiatric disorders.

 substance use
Suicide
Affective disorders

Impulse-control disorders
Eating disorders, and anxiety disorders.

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 Con....
 Increases personal incapacitation, morbidity, and mortality of
these patients.
 Persons with PDs are far more likely to refuse psychiatric help
and to deny their problems than persons with anxiety disorders,
depressive disorders, or obsessive-compulsive disorder.
 PD symptoms are
 ego syntonic (i.e., acceptable to the ego) and

 alloplastic (i.e., adapt by trying to alter the external

environment rather than themselves).
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 Cont….
 Persons with PDs do not feel anxiety about their maladaptive
behavior.
 They do not routinely acknowledge pain from what others
perceive as their symptoms
 They often seem disinterested in treatment and impervious to
recovery.

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 Normal versus Deviant Personality

 Normal personality is usually defined:

1. Directly, using criteria of health ideals

2. Indirectly, as the opposite to deviant personality, or most

frequently
3. Statistically, by behaviors that are most common in the
given environment.

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 Characteristics of Personality Disorders
 Inflexible, socially maladaptive behaviors

 Self-centeredness
 Manipulative(control) and exploitative(unfair) behavior
 Inability to tolerate minor stress

 Lack of individual accountability for behavior, blaming others

for their problems
 Difficulty dealing with reality
 Vulnerability to other mental disorders

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 Types of personality disorders
 Based on descriptive similarities; the personality disorders are
grouped into three clusters:

Cluster A (odd/eccentric, aloof features)

1.Paranoid personality disorder

2.Schizoid personality disorder
3.Schizotypal personality disorder

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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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 General criteria for Personality Disorder
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).
2. Affectivity (i.e., the range, intensity, liability, and
appropriateness of emotional response).

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 Personality disorder …con’t

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.

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 Personality disorder …con’t
D. The pattern is stable and of long duration, and Its onset can be
traced back at least to adolescence or early adulthood.

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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 Diagnostic Features

 The diagnosis of personality disorders requires an

evaluation of the individual's long-term patterns of
functioning
 The particular personality features must be evident by
early adulthood.
 Assessment can also be complicated by the fact that the
characteristics that define a PD may not be considered
problematic by the individual.

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 Development and Course

 The features of a PD usually become recognizable during

adolescence or early adult life.
 Some types of PD (notably, antisocial and borderline PDs) tend to
become less evident or to remit with age.
 whereas this appears to be less true for some other types (e.g.,
obsessive-compulsive and schizotypal PDs).
 PD to be diagnosed in an individual younger than 18 years.
 The one exception to this is antisocial PD, which cannot be
diagnosed in individuals younger than 18 years.

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 The features must have been present for at least 1 year.

 PD requires an onset no later than early adulthood.

 Individuals may not come to clinical attention until relatively late
in life.
 PD may be exacerbated following the loss of significant
supporting persons(e.g., a spouse) or previously stabilizing social
situations (e.g., a job).

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 Differential Diagnosis

 Other mental disorders

 Some PDs may have a "spectrum" relationship to other
mental disorders .
 schizotypal personality disorder with schizophrenia

 avoidant personality disorder with social anxiety disorder

[social phobia])
 Personality traits are diagnosed as a PD only when they
are inflexible, maladaptive, and persisting and cause
significant functional impairment or subjective distress
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 ETIOLOGY
1. Biological
 Genetic Factors

 PDs among monozygotic twins was several times that among

dizygotic twins.
 Cluster A personality disorders are more common in the biological
relatives of patients with schizophrenia
 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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 Genetic Factor…con.t

Cluster B personality disorders also have a genetic base.:-

 Antisocial PD is associated with alcohol use disorders.
 Depression is common in the family backgrounds of patients
with borderline personality disorder.
 A strong association is found between histrionic PD and
somatization disorder.

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 Genetic Factor…con.t

Cluster C personality disorders:-

 Patients with avoidant personality disorder often have high
anxiety levels.
 Obsessive-compulsive traits are more common in monozygotic
twins than in Dizygotic twins.

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 Cont…

 Hormones
 High levels of testosterone, 17-estradiol, and estrone
in a persons who exhibit impulsive traits
 Platelet Monoamine Oxidase
 Low platelet monoamine oxidase (MAO) levels
have been associated with activity and sociability in
monkeys.
 College students with low platelet MAO levels
report spending more time in social activities than
students with high platelet MAO levels.
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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
 Electrophysiology
 slow-wave activity on EEGs occur in some patients with
personality disorders, most commonly antisocial and
borderline types

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 Cont…

2.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
 an anal character are stubborn, parsimonious, and highly
conscientious because of struggles over toilet training during the
anal period.
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 Defense Mechanisms in PDs
 Is the unconscious mental processes that the ego uses to
resolve conflicts
 When defenses are most effective, especially in those
with personality disorders, they can abolish anxiety and
depression at the conscious level.
 Thus, abandoning a defense increases conscious
awareness of anxiety and depression—a major reason that
those with personality disorders are reluctant to alter their
behavior.
 Although patients with personality disorders may be
characterized by their most dominant or rigid mechanism,
each patient uses several defenses.

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 Defense Mechanisms…con.t
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.
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

 In a crisis, patients may show intensified self-restraint, overly
formal social behavior, and obstinacy.
 such patients respond well to precise, systematic, and rational
explanations and value efficiency, cleanliness, and punctuality
4.Projection
 patients attribute their own unacknowledged feelings to others
 excessive faultfinding and sensitivity to criticism

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 Cont…

5.SPLITTING
 In splitting, persons toward whom patients’ feelings are, or
have been, ambivalent are divided into good and bad.
 For example, in an inpatient setting, a patient may idealize
some staff members and uniformly disparage others
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
 Tantrums, apparently motiveless assaults, child abuse, and
pleasureless promiscuity are common examples.

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 Cluster A personality disorders
Cluster A (odd or eccentric)
1) paranoid
2) schizoid
3) Schizotypal

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 1. Paranoid personality disorder (ppd)

 Persons with PPD are characterized by long-standing

suspiciousness and mistrust of persons in general.
 They refuse responsibility for their own feelings and assign
responsibility to other.
 They are often hostile, irritable, and angry.
 Bigots, pathologically jealous spouses, and litigious cranks( an
eccentric )

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 Diagnosis

o Muscular tension, an inability to relax, and a need to

scan the environment for clues may be evident, and the
patient's manner is often humorless (sad ) and serious.
o 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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 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
 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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 Epidemiology

o The prevalence of PPD is 2 to 4 % of the general population.

o More specific familial relationship with delusional disorder,
persecutory type.
o More commonly diagnosed in men than in women.

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 DSM-5 Diagnostic Criteria for PPD

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.

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 Con.t

3.Is reluctant (unwilling) 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 (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
counterattack.
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7. Has recurrent suspicions, without justification, regarding
fidelity of spouse or sexual partner.
B. Does not occur exclusively other mental disorders and
medical conditions

Note: If criteria are met prior to the onset of schizophrenia, add

premorbid, i.e., paranoid personality disorder (premorbid).

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 Differential Diagnosis
 Delusional disorder: Paranoid personality disorder can usually
be differentiated from delusional disorder by the absence of fixed
delusions.
 paranoid schizophrenia: Unlike persons with paranoid
schizophrenia, those with personality disorders have no
hallucinations or formal thought disorder.
 antisocial behavior: Patients with paranoia lack the long history
of antisocial behavior
 schizoid personality disorder: Persons with schizoid
personality disorder are withdrawn and aloof and do not have
paranoid ideation.

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 Course and Prognosis

 No adequate, systematic long-term studies of paranoid personality

disorder have been conducted.
 In some, paranoid personality disorder is lifelong.
 It is a harbinger (sign) of schizophrenia

 Paranoid traits give way to reaction formation

 In general, however, those with paranoid personality disorder have
lifelong problems working and living with others.
 Occupational and marital problems are common.

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 Treatment

 Psychotherapy is the treatment of choice for those with

paranoid personality disorder.
 Individual psychotherapy and social skills training.
 An anti anxiety agent such as diazepam and an
antipsychotic such as haloperidol (Haldol) in small
dose.

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 2. Schizoid personality disorder

o Schizoid personality disorder is characterized by a lifelong

pattern of social withdrawal.
o Persons with SPD are often seen by others as
o eccentric(unconventional and strange),
o isolated, or

o lonely.
o Their discomfort with human interaction; their introversion; and
their bland, constricted affect are noteworthy.

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 Epidemiology

 The prevalence of SPD 5 % of the general population.

 The sex ratio of the disorder is unknown; some studies
report a 2-to-1 male-to-female ratio
 Persons with the disorder tend to gravitate toward solitary
jobs that involve little or no contact with others.
 Many prefer night work to day work so that they need not
deal with many persons.

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 Diagnosis

 They rarely tolerate eye contact.

 Their affect may be

constricted,
aloof (cool and distant), or

inappropriately serious.
 These patients find it difficult to be lighthearted:
 Their speech is goal directed.

 Their sensorial is intact.

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 Cont…

 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
 Their sexual lives may exist exclusively in fantasy

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 Cont…

 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
 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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 DSM-5 Diagnostic Criteria for Schizoid Personality Disorder

 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.
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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 others mental disorders and of
another medical condition.

Note: If criteria are met prior to the onset of schizophrenia, add

premorbid, schizoid personality disorder (premorbid).

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 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 in the latter.

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 Cont…
4) paranoid personality disorder
=>Although patients with paranoid personality disorder share
many traits with those with schizoid personality disorder, the
former exhibit more:-
 more social engagement

 history of aggressive verbal behavior and

 greater tendency to project their feelings onto others

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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

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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 Course and Prognosis

o The onset of schizoid personality disorder usually

occurs in early childhood or adolescence.
o As with all personality disorders, schizoid personality
disorder is long lasting but not necessarily lifelong.
o The proportion of patients who incur schizophrenia is
unknown.

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 Treatment
In group psychotherapy.

 Pharmacotherapy with 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.
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 3. Schizotypal personality disorder

 Persons with schizotypal personality disorder are

strikingly odd or strange, even to laypersons.
 Magical thinking, peculiar notions, ideas of
reference, illusions, and derealization are part of a
schizotypal person’s everyday world.

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 Clinical Features

 Persons with schizotypal personality disorder are strikingly odd

or strange
 They exhibit disturbed thinking and communication
 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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  Schizotypal personality disorder is 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 communicating.

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 Epidemiology

 SPD occurs in about 3 % of the population.

 The sex ratio is unknown; however, it is frequently
diagnosed in females with fragile X syndrome.
 Slightly more common in males.
 A greater association of cases exists among the
biological relatives of patients with schizophrenia
 Higher incidence among monozygotic twins than
among Dizygotic twins (33 % vs. 4 % in one study).

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 DSM-5 Diagnostic Criteria for Schizotypal Personality
Disorder

A. A pervasive pattern of social and interpersonal deficits marked

by acute discomfort with
 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).

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2. Odd beliefs or magical thinking that influences behavior and is
inconsistent with sub cultural norms (e.g., superstitiousness,
belief in clairvoyance (power to see into the future), telepathy ,
(communication by means other than sense) 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, over elaborate, or stereotyped).

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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 other mental
disorders
Note: If criteria are met prior to the onset of schizophrenia, add
“premorbid,”
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 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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 Course and Prognosis

 The schizotype is the premorbid personality of the

patient with schizophrenia.
 10 percent of those with schizotypal personality disorder
eventually committed suicide.

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 Treatment
 Psychotherapy
 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 (dramatic, emotional, or erratic)
1) Antisocial
2) Borderline
3) Histrionic and
4) Narcissistic

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 1. Antisocial Personality Disorder(APD)

 APD is an inability to conform to the social norms that

ordinarily govern many aspects of a person's adolescent and
adult behavior.

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 Epidemiology
 The 12-month prevalence rates of APD are between 0.2 and 3%.

 It is more common in poor urban areas and among mobile

residents of these areas.
 Men with alcohol use disorder (>70% and in prison populations(
75%).
 It is more common in males than in females.

 The onset of the disorder is before the age of 15 years.

 Girls usually have symptoms before puberty and boys even
earlier.
 5X more common among first-degree relatives of men.
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 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
 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
 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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 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)
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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 DSM-5 Diagnostic Criteria for Antisocial Personality
Disorder
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.
2. Deceitfulness, as indicated by repeated lying, use of aliases, or
conning others for personal profit or pleasure.

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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.

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.

01/03/2022 By Giruman 76
 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 is not exclusively during the course
of schizophrenia or bipolar disorder.

01/03/2022 By Giruman 77
 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
01/03/2022 By Giruman 78
 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

01/03/2022 By Giruman 79
 Course and Prognosis

 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.
01/03/2022 By Giruman 80
 Treatment

 Psychotherapy
 Psycho stimulants such as methylphenidate.
 Antiepileptic drugs, for example, carbamazepine
(Tegretol) or valproate (Depakote),

01/03/2022 By Giruman 81
 2.Borderline personality disorder

 Patients with BPD stand on the border between neurosis and

psychosis.
 They are characterized by extraordinarily unstable affect, mood,
behavior object relations, and self-image.
 The disorder has also been called
 ambulatory schizophrenia
 pseudo neurotic schizophrenia psychotic character disorder

 Emotionally unstable personality disorder.

01/03/2022 By Giruman 82
 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.
01/03/2022 By Giruman 83
 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

01/03/2022 By Giruman 84
 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)
 They distort their relationships by considering each
person to be either all good or all bad.

01/03/2022 By Giruman 85
 Epidemiology

 BPD is thought to be present in about 1 to 2 % of the

population
 BPD Is twice as common in women as in men.
 An increased prevalence of major depressive disorder,
alcohol use disorders, and substance abuse is found in
first-degree relatives of persons with BPD.

01/03/2022 By Giruman 86
 DSM-5 Diagnostic Criteria for Borderline
Personality Disorder
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:
1. Frantic efforts to avoid real or imagined abandonment. (Note:
Do not include suicidal or self-mutilating behavior covered in
Criterion 5.)

01/03/2022 By Giruman 87
2.A pattern of unstable and intense interpersonal relationships
characterized by alternating between extremes of idealization
and devaluation.
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.
01/03/2022 By Giruman 88
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).
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.
01/03/2022 By Giruman 89
 Differential Diagnosis
1.Schizophrenia
=>patient with borderline personality lacks prolonged psychotic
episodes, thought disorder, and other classic schizophrenic signs
2.Schizotypal personality disorder
=> Patients with schizotypal personality disorder show marked
peculiarities of thinking, strange ideation, and recurrent ideas of
reference
3.paranoid personality disorder

=>patients with ppd disorder are marked by extreme

suspiciousness, but patients with borderline personality disorder
generally have chronic feelings of emptiness and short lived
psychotic episodes
01/03/2022 By Giruman 90
 Course and Prognosis

 BPD is fairly stable; patients change little over time.

 No progression toward schizophrenia, but patients have

a high incidence of major depressive disorder episodes.
 Patients are attempting to make occupational, marital,
and other choices and are unable to deal with the normal
stages of the life cycle

01/03/2022 By Giruman 91
 Treatment

 A reality-oriented approach is more effective than in-

depth interpretations of the unconscious.
 Social skills training
 an individual
 a group basis

 Occupational
 recreational, and vocational therapy and up to 1
year in some cases.

01/03/2022 By Giruman 92
 Antipsychotics
 Antidepressants
 The MAO inhibitors (MAOIs) have successfully
modulated impulsive behavior in some patients
benzodiazepines anticonvulsants.

01/03/2022 By Giruman 93
 3. Histrionic Personality Disorder(HPD)

 Persons with HPD are

 excitable

 emotional
 behave in a colorful, dramatic, extroverted fashion.
 Accompanying their flamboyant aspects.

 often an inability to maintain deep, long-lasting

attachments.

01/03/2022 By Giruman 94
 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

01/03/2022 By Giruman 95
 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

01/03/2022 By Giruman 96
 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
01/03/2022 By Giruman 97
 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

01/03/2022 By Giruman 98
 Epidemiology

 Prevalence HPD of about 1 to 3 % in general

population.
 In inpatient and outpatient mental health settings
10 -15% of prevalence.
 In women more common than in men.
 Some studies have found an association with
somatization disorder and alcohol use disorders.

01/03/2022 By Giruman 99
DSM-5 Diagnostic Criteria for Histrionic Personality Disorder

A. A pervasive pattern of excessive emotionality and

attention seeking, beginning by early adulthood, as

indicated by five or more of the following:
1. The patient is not comfortable unless he is the
center of attention.
2. The patient is often inappropriately sexually
seductive or provocative with others.

01/03/2022 By Giruman 100

3. Rapidly shifting and shallow expression of emotions are
present.

4. The patient consistently uses physical appearance to

attract attention.
5. Speech is excessively impressionistic and lacking in detail.
6. Dramatic, theatrical, and exaggerated expression of emotion
is used.
7. The patient is easily influenced by others or by
circumstances.
8. Relationships are considered to be more intimate than they
are in reality.
01/03/2022 By Giruman 101
 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
01/03/2022 By Giruman 102
 Course and Prognosis

o With age, persons with histrionic personality disorder

show fewer symptoms.
o Persons with this disorder are sensation seekers
o They may get into trouble with the
 Law

 abuse substances
 act promiscuously.

01/03/2022 By Giruman 103

 Treatment

 Insight-oriented psychotherapy is the treatment of

choice.
 Pharmacotherapy can be adjunctive when
symptoms are targeted
 antidepressants for depression and somatic
complaints
 ant anxiety agents for anxiety
 antipsychotics
01/03/2022 By Giruman 104
 4. NARCISSISTIC PERSONALITY DISORDER

 Characterized by
 A heightened sense of self-importance
 Lack of empathy

 Grandiose feelings of uniqueness

o Underneath, however, their self-esteem is fragile and
vulnerable to even minor criticism.
o they consider themselves special and expect special
treatment
01/03/2022 By Giruman 105
• Persons with narcissistic personality disorder have a grandiose
sense of self-importance; they consider themselves special and
expect special treatment.
• Their sense of entitlement is striking.
• They handle criticism poorly and may become enraged when
someone dares to criticize them, or they may appear
completely indifferent to criticism.

01/03/2022 By Giruman 106

• They cannot show empathy, and they feign sympathy only
to achieve their own selfish ends.
• Because of their fragile self-esteem, they are susceptible
to depression.
• Interpersonal difficulties, occupational problems,
rejection, and loss are among the stresses that narcissists
commonly produce by their behavior—stresses they are
least able to handle.
01/03/2022 By Giruman 107
 Epidemiology
 Its prevalence range from less than 1 to 6 %.

 More commonly diagnosed in males (50 to 75

percent ).

01/03/2022 By Giruman 108

 DSM-5 Diagnostic Criteria for Narcissistic Personality Disorder

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).
01/03/2022 By Giruman 109
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.

01/03/2022 By Giruman 110

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).

7. Lacks empathy: is unwilling to recognize or identify with

the feelings and needs of others.
8. Is often envious (feel discontent) of others or believes
that others are envious of him or her.
9. Shows arrogant, haughtyBybehaviors
01/03/2022 Giruman
or attitudes. 111
 Differential Diagnosis

 Manic
 Hypomania

 Obsessive-Compulsive
 Paranoid, Schizotypal, Borderline, histrionic,
and antisocial personality disorders

01/03/2022 By Giruman 112

 Course and Prognosis

o Narcissistic personality disorder is chronic and

difficult to treat.
o Aging is handled poorly; may be more
vulnerable
o midlife crises than are other groups.

01/03/2022 By Giruman 113

 Treatment

 Group therapy
 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.

01/03/2022 By Giruman 114

 Cont…
Cluster C (anxious or fearful)
1) Avoidant
2) Dependent and
3) Obsessive compulsive

01/03/2022 115
 1.Avoidant personality disorder
 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
01/03/2022
disorder
By Giruman 116
 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
01/03/2022 By Giruman 117
 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

01/03/2022 By Giruman 118

 Epidemiology

o The prevalence of 2 to 3 % of the general

population.
o The male-to-female ratio is 1:1.
o Adults with avoidant personality disorder were
frequently shy as children, childhood shyness .

01/03/2022 By Giruman 119

DSM-5 Diagnostic Criteria for Avoidant
Personality Disorder.
 A pervasive pattern of
 social inhibition
 feelings of inadequacy

 Hypersensitivity
 to negative evaluation
 beginning by early adulthood

 present at variety of contexts indicated by at least four of the

following:
01/03/2022 By Giruman 120
 Con.t

1.The patient avoids occupational activities with significant

interpersonal contact due to fear of criticism, disapproval or
rejection.
2.is unwilling to get involved with people unless certain of being
liked.
3. shows Restrained in intimate relationships due to fear of
being shamed or ridiculed.
• 4. Preoccupied with being criticized or rejected in social
situations.

01/03/2022 By Giruman 121

5. Inhibited in new interpersonal situations due to feelings
of inadequacy.
6.The patient views himself as socially inept… incompetent,
unappealing or inferior to others.

7. is unusually reluctance to take personal risks or to

engage in new activities because they may be
embarrassing

01/03/2022 By Giruman 122

 Differential Diagnosis
1.Schizoid personality disorder
 Patients with avoidant personality disorder desire social
interaction, unlike patients with schizoid personality disorder,
who want to be alone.
2.borderline personality disorder
3.histrionic personality disorder
 =>Patients with avoidant personality disorder are not as
demanding, irritable, or unpredictable as those with borderline
and histrionic personality disorders.
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

01/03/2022 By Giruman 123

 Course and Prognosis

 Frequently begins in childhood with shyness and fear

of strangers and new situations.
 Many persons with avoidant personality disorder are
able to function in a protected environment.

01/03/2022 By Giruman 124

 Treatment

o Individual psychotherapy
o group psychotherapy may assist in dealing with
social anxiety.
o Behavioral techniques, such as assertiveness
training and systematic desensitization, may help
the patient to overcome anxiety and shyness.
o Beta-blockers can be useful for situational anxiety
o Antidepressants(SSRI) or anxiolytics.
01/03/2022 By Giruman 125
 2.Dependent personality disorder

Characteristics
Subordinate for their own needs
Lack of self confidence
May experience intense discomfort when alone
for more than a brief period.
o The disorder has been called passive -dependent
personality.

01/03/2022 By Giruman 126

 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

01/03/2022 By Giruman 127

 Oral-dependent
personality dimension
characterized by:
dependence
pessimism
fear of sexuality
self-doubt
passivity
suggestibility
lack of perseverance.

01/03/2022 By Giruman 128

 Epidemiology

 More common in women than in men.

 It's prevalence of 0.6 %.
 2.5 percent of all personality disorders as falling
into this category
 It is more common in young children than in older
ones.
 Persons with chronic physical illness in childhood
may be most susceptible.
01/03/2022 By Giruman 129
 DSM-5 Diagnostic Criteria for Dependent
Personality Disorder
• A pervasive and excessive need to be taken care of that
leads to
o submissive
o clinging behavior
o fears of separation

o beginning by early adulthood and present in a variety of

contexts,

• as indicated by five (or more) of the following:

01/03/2022 By Giruman 130
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 (because of a lack of self-confidence in judgment or abilities
rather than a lack of motivation or energy).
 Note: Do not include realistic fears of retribution.
01/03/2022 By Giruman 131
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.
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 him/herself.

01/03/2022 By Giruman 132

 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

3.Agoraphobia
 these patients tend to have a high level of overt anxiety or even panic
in addition to dependence behavior
01/03/2022 By Giruman 133
 Course and Prognosis

o Occupational functioning tends to be impaired.

o Social relationships are limited.
o They have of risk major depressive disorder

01/03/2022 By Giruman 134

 Treatment

 Insight-oriented therapies
 Behavioral therapy
 Assertiveness training
 Family therapy
 Group therapy

01/03/2022 By Giruman 135

Pharmacotherapy
 Pharmacotherapy has been used to deal with specific symptoms,

such as anxiety and depression, which are common associated

features of dependent personality disorder.

• Patients who experience panic attacks or who have high levels of

separation anxiety may be helped by imipramine (Tofranil).

• Benzodiazepines and serotonergic agents have also been useful.

01/03/2022 By Giruman 136

 Obsessive-Compulsive Personality Disorder(OCPD)

OCD is characterized by
 emotional constriction

 Orderliness

 Perseverance

 Stubbornness
 Indecisiveness
The essential feature of the disorder is a pervasive
pattern of perfectionism and inflexibility.
01/03/2022 By Giruman 137
 preoccupied with rules, regulations, orderliness,
neatness, details, and the achievement of perfection
 they are formal and serious and often lack a sense of
humor
o their mood is usually serious.
o their answers to questions are unusually detailed

o they use defense mechanisms like rationalization,

intellectualization,

01/03/2022 By Giruman 138

 Epidemiology

 Prevalence ranging from 2 to 8 percent.

 more common in men than in women(2:1)
 is diagnosed most often in oldest siblings.
 The disorder also occurs more frequently in first-
degree biological relatives.

01/03/2022 By Giruman 139

 DSM-5 Diagnostic Criteria for OCPD

 A pervasive pattern of preoccupation with

 orderliness

 perfectionism
 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:

01/03/2022 By Giruman 140

1. Is preoccupied with details, rules, lists, order, organization, or
schedules to the extent that the major point of the activity is lost.

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).

4. Is over conscientious, scrupulous, and inflexible about matters
of morality, ethics, or values (not accounted for by cultural or
religious identification).

01/03/2022 By Giruman 141

5. Is unable to discard worn-out or worthless objects even when
they have no sentimental value.
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.

01/03/2022 By Giruman 142

 Differential Diagnosis

 OCD
 When recurrent obsessions or compulsions are
present, obsessive-compulsive disorder should be
noted.
 Hoarding disorder

01/03/2022 By Giruman 143

 Course and Prognosis

• Harbinger (sign) of schizophrenia Exacerbated by the

aging process MDD.
• Persons with OCPD may flourish in positions
 demanding methodical
 Deductive , (general to specific) or detailed work
 they are vulnerable to unexpected changes, and their
personal lives may remain barren.

01/03/2022 By Giruman 144

 Treatment

o Group therapy and behavior therapy occasionally offer

certain advantages.
o Long-term, individual therapy is usually helpful
o Clonazepam (Klonopin), a benzodiazepine with
anticonvulsant use
o Clomipramine (Anafranil) and fluoxetine, usually at
dosages of 60 to 80 mg a day

01/03/2022 By Giruman 145

 OTHER SPECIFIED PERSONALITY DISORDER

 Passive aggressive personality

 Depressive personality.

 Oppositionalism
 sadism, or masochism

01/03/2022 By Giruman 146

 Passive-Aggressive Personality

 Although no longer an official diagnosis, persons with

this personality type are not uncommon.
 Persons with passive-aggressive personality are
characterized by covert obstructionism,
procrastination, stubbornness, and inefficiency.
 Such behavior is a manifestation of passively
expressed underlying aggression.

01/03/2022 By Giruman 147

 Clinical Features

 Patients with passive-aggressive personality characteristically

 Procrastinate, resist demands for adequate performance, find

excuses for delays, find fault with those on whom they depend.
 They usually lack assertiveness and are not direct about their
own needs and wishes.
 Self-detrimental behavior as punitive and manipulative.

 lack self-confidence and are typically pessimistic about the

future.

01/03/2022 By Giruman 148

 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.

Epidemiology
o Depressive personality type seems to be common and to
occur in families in which depressive disorders are found
o Equally in men and women

01/03/2022 By Giruman 149

 Clinical Features
 They are often meticulous, perfectionist, over
conscientious, and preoccupied with work; feel
responsibility keenly; and are easily discouraged
under new conditions.
 They are fearful of disapproval; tend to suffer in
silence; and perhaps to cry easily, although usually
not in the presence of others.

01/03/2022 By Giruman 150

 A tendency to hesitation, indecision, and caution
betrays an inherent feeling of insecurity.
 More recently, Hagop Akiskal described seven groups
of depressive traits:
1.quiet, introverted, passive, and nonassertive
2. gloomy, pessimistic, serious, and incapable of fun
3. self-critical, self-reproachful, and self-derogatory;

01/03/2022 By Giruman 151

4. skeptical, critical of others, and hard to please
5. conscientious, responsible, and self-disciplined
6. brooding and given to worry
7. preoccupied with negative events, feelings of
inadequacy, and personal shortcomings.

01/03/2022 By Giruman 152

 Sadomasochistic Personality

• Sadism is the desire to cause others pain by being either

 sexually abusive

 physically or psychologically abusive.

o persons who experienced sexual pleasure while inflicting pain on
others.
• Masochism is the achievement of sexual gratification by inflicting pain
on the self.
• So-called moral masochists generally seek humiliation and failure
rather than physical pain.
o sadistic and masochistic behavior are usually present in the same
person.
01/03/2022 By Giruman 153
• Treatment with insight-oriented psychotherapy.
 Personality change due to a general medical condition

 Personality and behavioral disorders due to brain

disease, damage, and dysfunction, which includes
 organic personality disorder
 post encephalitic syndrome

 postconcussional syndrome

01/03/2022 By Giruman 154

 Medical Conditions Associated with
Personality Change
o head trauma
o cerebrovascular diseases
o cerebral tumors
o Epilepsy
o Huntington's disease
o multiple sclerosis
o endocrine disorder
o heavy metal poisoning
o Neurosyphilis and AIDS

01/03/2022 By Giruman 155

 Diagnosis and Clinical Features

 Impaired control of the expression of emotions and

impulses is a cardinal feature.
 Damage to the frontal lobes, the so-called frontal lobe
syndrome, characterized by
 a lack of concern for events in the immediate
environment.

01/03/2022 By Giruman 156

 The expression of impulses may be manifested by
 inappropriate jokes
 a coarse manner

 improper sexual
 antisocial conduct

01/03/2022 By Giruman 157

 Thank you for your attention

3/3/2020 158
 Individual assignments
1. Dialectical behavior therapy…… Teshome
2. Insight oriented psychotherapy ….Zebiba
3. Transference-focused psychotherapy..kelem
4. Free association….fenel
5. Person centered therapy..setegn
6. Mentalization-based therapy..Aman
7. Cognitive therapy…mekdes
8. Inter personal therapy …ebsie
9. Temperament personality….beti
10. Big five personality ..melkamu
11.Character vs personality…kalkidan
12.Personality development with its stage….mule
13. Stage of psychosexual development …eman
14. Personality vs Identity ….tamirat

01/03/2022 By Giruman 159