Personality disorders

Dr Asmeret Andebirhan
July 12/2023
Medical students Lecture

personality disorder 08/07/2023 1

Objectives
 Define the word “Personality”…..
 Recall 4 core domains for assessing

personality
 List types of personality disorders
 Describe diagnostic criteria and principle of

management of personality disorders

personality disorder 08/07/2023 2

Outline
 Definitions of personality
 Criteria for general personality disorder
 Etiology
 Epidemiology
 Diagnostic criteria
 Principle of management

personality disorder 08/07/2023 3

Definition
 Personality is neither exclusively mental nor
exclusively neural but a combination of the
two,
• According to Allport defined as the
“dynamic organization with in the individual
of those pschophysiological systems that
determines his/her unique adjustment to
his or her environment.”

personality disorder 08/07/2023 4

personality disorder 08/07/2023 5
 Personality traits consist of enduring patterns
of perceiving, relating to, and thinking about
the environment, other people and oneself.
 Ego syntonic ( accepted by the ego ) and
alloplastic
• When personality traits become
-Inflexible
-Maladaptive
-Impairing
-stressful

personality disorder 08/07/2023 6

Etiology
• Genetic factors
 Ixs of >15000 pairs of twins in U.S- concordance for
personality disorder among monozygotic was several
times higher than that of among diazygotic twins
 Cluster A personality disorders are common in the
biological relatives of patient with schizophrenia than
in control groups; more relatives with schizotypal
personality disorder occur in the family hxs of persons
with schizophrenia than in control groups;
 Depression is common in families of patients with
borderline personality disorder;

personality disorder 08/07/2023 7

• Biological factors
 Hormones- persons who exhibits impulsive traits show high level
of testosterone, 17-estradiol and estrone
 Low MAO enzyme level associated with activity and sociability in
monkeys; college students with low platelet MAO levels reports
spending more time in social activities than students with high
platelet MAO levels
 Neurotransmitters- serotonin and dopamine(level of 5-
hydroxyindoleacetic acid (5-HIAA))metabolites of serotonin are
low in persons who attempt suicide and in patients who are
impulsive and aggressive; in many persons, serotonin reduces
depression, impulsiveness and can produce a sense of wellbeing;
increase in dopamine concentration in CNS produce euphoria
 Electrophysiology- change in EEG- slow wave activity( most
commonly in antisocial and borderline type)

personality disorder 08/07/2023 8

• Psychoanalytic factors
 Sigmund Freud suggested that personality traits are
related to a fixation at one psychosexual stage of
development; those who are fixated at oral stage are
passive and dependent( on others for food is prominent);
those who are fixated at anal stage are stubborn,
parsimonious, highly conscientious because of struggle
over toilet training during anal period
 Personality disorder is due to the absence of mature
defense mechanisms
 Defense mechanisms- unconscious mental process that
the ego uses to resolve conflict among the four lodestars
of: instinct(wish or need), reality, important others and
conscience

personality disorder 08/07/2023 9

Fantasy- schizoid personality disorder; in their extensive
dependence on fantasy, those persons often seem to be
distant; physicians should understand their fear of intimacy;
don’t judge them by rejection,
Dissociation or denial- histrionic , schizoid, dependent, anti
social personality disorder; replacement of unpleasant affects
with pleasant one; physicians should be calm and firm
because the patients are “non-deliberate liars”,
Isolation- OCPD; unlike histrionic personality disorder patients
with OCPD remember the truth in details but without affect; in
crisis, patients may show intensified self restraint, overly
formal social behavior and obstinacy,
Projection- paranoid , schizotypal, narcissistic personality
disorder; patients attribute their own unacknowledged feelings
to others,

personality disorder 08/07/2023 10

Splitting- borderline personality disorder; patient may
idealize some staff members and uniformly disparage others
Passive aggression-through therapy physician can help the
patient to ventilate their anger
Acting out- anti social, narcissistic; patient directly express
unconscious wishes or conflicts through action to avoid
being conscious of either the accompanying idea or the
affect
Projective identification- borderline personality disorder; an
aspect of self is projected to someone else(recipient)_
projector tries to force the other person into identifying with
what has been projected_the recipient and the projector feel
a sense of oneness or union-the recipient act or feel in
accordance with what has been projected

personality disorder 08/07/2023 11

Cluster A personality
disorders
Odd and aloof features

personality disorder 08/07/2023 12

personality disorder 08/07/2023 13
Epidemiology
 Prevalence is 2-4%
 M>F
 Projection

personality disorder 08/07/2023 14

Treatment
 Psychotherapy
◦ Therapist should be straight forward
◦ Individual- better for these patients due to their
paranoia
◦ Group – to improve their social skills and
suspiciousness
◦ Difficulty with trust and toleration of intimacy
◦ Overuse of interpretation might increase their fear
of trust

personality disorder 08/07/2023 15

 Pharmacotherapy
◦ Antianxiety agent- BDZs ( diazepam )- for agitation
and anxiety
◦ Antipsychotics – haloperidol- For severe agitation
and delusional thinking-

personality disorder 08/07/2023 16

personality disorder 08/07/2023 17
Epidemiology
 Prevalence is 5%
 M:F = 2:1
 Denial and fantasy

personality disorder 08/07/2023 18

Treatment
 Psychotherapy
◦ Individual- great therapeutic alliance might reveal
their fantasies, imaginary friends and fear of
intimacy
◦ Group – may be silent for long period of time

personality disorder 08/07/2023 19

 Pharmacotherapy
◦ BDZs- Interpersonal anxiety
◦ Low dose of Antipsychotics and anti depressants
for psychotic or depressive presentation

personality disorder 08/07/2023 20

personality disorder 08/07/2023 21
Epidemiology
 Prevalence is 3%
 M>F
 Is premorbid personality of patients with

schizophrenia
 Projection, displacement

personality disorder 08/07/2023 22

Treatment
 Psychotherapy
◦ Individual
◦ Group
◦ Therapist shouldn’t be judgmental for oddities

personality disorder 08/07/2023 23

 Pharmacotherapy
◦ Antipsychotics ( illusion and ideas of reference )
◦ Antidepressants ( depressive component )

personality disorder 08/07/2023 24

Cluster B personality
disorders
Dramatic, impulsive and erratic

personality disorder 08/07/2023 25

personality disorder 08/07/2023 26
Epidemiology
 12 months prevalence is 0.2-0.3%
 M>F
 Age increase, symptoms got decrease
 Denial, acting out, omnipotent control,

projective identification

personality disorder 08/07/2023 27

Treatment
 Psychotherapy
◦ Group therapies( self help groups )
 Pharmacotherapy
◦ Anticonvulsants, lithium, and beta-blockers have
been used for impulse control problems
◦ Antidepressant- for depressive features

personality disorder 08/07/2023 28

personality disorder 08/07/2023 29
Epidemiology
 Prevalence 1-2%
 Twice as common in women as in men
 Splitting, projective identification

personality disorder 08/07/2023 30

Treatment
 Psychotherapy

◦ DBT- to deal with their parasuicidal behavior and

distress intolerance
 Is an integrated CBT
◦ Transference focused psychotherapy ( how splitting
affect their interpersonal relation )
◦ Mentalization based psychotherapy- mentalization-allow
a person to be attentive of a mental state of self and
other’s which comes from a persons awareness of
mental process and subjective states arise in
interpersonal interaction-Difficulty in regulating emotion
and managing impulsivity

personality disorder 08/07/2023 31

 Pharmacotherapy
◦ Antipsychotics- for anger, hostility and brief
psychotic episodes
◦ Antianxiety medications and antidepressants

personality disorder 08/07/2023 32

personality disorder 08/07/2023 33
Epidemiology
 F>M
 Prevalence 1-3%
 Denial, repression

personality disorder 08/07/2023 34

Treatment
 Psychotherapy
◦ Psychoanalytically oriented psychotherapy
( individual and group )

personality disorder 08/07/2023 35

 Pharmacotherapy
◦ Antidepressant- for depression
◦ Antianxiety agents- for anxiety
◦ Antipsychotic- for illusion and derealization

personality disorder 08/07/2023 36

personality disorder 08/07/2023 37
Epidemiology
 Prevalence <1-6%
 Offspring of such parents have higher than

usual risk
 M>F
 Repression, acting out, idealization,

devaluation

personality disorder 08/07/2023 38

Treatment
 Psychotherapy
 Pharmacotherapy
◦ Mood stabilizer- for mood swings
◦ Antidepressants- for depression

personality disorder 08/07/2023 39

Cluster C personality
disorders
Anxious and fearful

personality disorder 08/07/2023 40

personality disorder 08/07/2023 41
Epidemiology
 2-3% of general population
 F>M, F=M
 Repression, reaction formation,

intellectualization and rationalization

personality disorder 08/07/2023 42

Treatment
 Psychotherapy
◦ Fear of rejection
◦ Therapist must encourage the patient to move out
into the world to take what are perceived as great
risk of humiliation, rejection and failure
◦ Therapist should be cautious in giving assignment
related to social skills for the patient- failure might
reinforce their existing poor self esteem

personality disorder 08/07/2023 43

 Pharmacotherapy
◦ Serotonergic agents- for rejection sensitivity
◦ Beta blockers- for ANS hyperactivity when they
approached feared situation

personality disorder 08/07/2023 44

personality disorder 08/07/2023 45
Epidemiology
 F>M
 Prevalence 0.6%
 Denial, splitting, rationalization

personality disorder 08/07/2023 46

Treatment
 Psychotherapy
◦ Insight oriented psychotherapy
◦ Assertiveness training
◦ Family therapy
◦ Group therapy
◦ To make patients independent, assertive and self
reliant

personality disorder 08/07/2023 47

 Pharmacotherapy
◦ Panic attack and separation anxiety- imipramine
◦ BDZs and serotonergic agents

personality disorder 08/07/2023 48

personality disorder 08/07/2023 49
Epidemiology
 M>F
 Prevalence 2-8%
 More frequent in first degree biological

relatives
 Often have backgrounds of harsh discipline
 Isolation, undoing, reaction formation,

intellectualization, rationalization

personality disorder 08/07/2023 50

Treatment
 psychotherapy

personality disorder 08/07/2023 51

 Pharmacotherapy
◦ Serotonergic agents for break through obsessive
and compulsive presentations

personality disorder 08/07/2023 52

Dissociative Disorders

personality disorder 08/07/2023 53

Dissociation

 In psychiatry, dissociation is defined as an

unconscious defense mechanism involving
the segregation of any group of mental or
behavioral processes from the rest of the
person’s psychic activity.

personality disorder 08/07/2023 54

 Dissociative disorders involve this mechanism
so that there is a disruption in one or more
mental functions, such as memory, identity,
perception,
 consciousness, or motor behavior. The

disturbance may be sudden or gradual,

transient
 or chronic, and the signs and symptoms of

the disorder are often caused by

 psychological trauma.

personality disorder 08/07/2023 55

DISSOCIATIVE AMNESIA

inability to recall important personal

information,
 usually of a traumatic or stressful nature that

is too extensive to be explained by normal

forgetfulness.
 the disorder does not result from the direct

physiological effects of a substance or a

neurological or other general medical
condition

personality disorder 08/07/2023 56

DSM V

personality disorder 08/07/2023 57

Case Example
A 45-year-old, divorced, left-handed, male bus dispatcher was seen in
psychiatric
consultation on a medical unit. He had been admitted with an episode of chest
discomfort, light-headedness, and left-arm weakness. He had a history of
hypertension
and had a medical admission in the past year for ischemic chest pain, although
he had not suffered a myocardial infarction. Psychiatric consultation was called,
because the
patient complained of memory loss for the previous 12 years, behaving and
responding to the environment as if it were 12 years previously (e.g., he did not
recognize his 8-year-old son, insisted that he was unmarried, and denied
recollection
of current events, such as the name of the current president). Physical and
laboratory
findings were unchanged from the patient’s usual baseline. Brain computed
tomography (CT) scan was normal.

personality disorder 08/07/2023 58

On mental status examination, the patient displayed intact intellectual function
but insisted that the date was 12 years earlier, denying recall of his entire
subsequent personal history and of current events for the past 12 years. He was
perplexed by the contradiction between his memory and current circumstances.
The patient described a family history of brutal beatings and physical discipline.
He was a decorated combat veteran, although he described amnestic episodes
for some of his combat experiences.
In the military, he had been a champion golden glove boxer noted for his
powerful left hand. He was educated about his disorder and given the
suggestion that his memory could return as he could tolerate it, perhaps
overnight during sleep or perhaps over a longer
time. If this strategy was unsuccessful, hypnosis or an amobarbital (Amytal)
interview was proposed.

personality disorder 08/07/2023 59

Epidemiology
 Dissociative amnesia has been reported in approximately 2 to 6

percent.
Etiology
• conflictual, with the patient experiencing intolerable
• emotions of shame, guilt, despair, rage, and desperation.
• Unacceptable urges or impulses include intense sexual, suicidal,

or violent compulsions.
• Traumatic experiences such as physical or sexual abuse can

induce the disorder.

• In some cases, the trauma is caused by a betrayal by a trusted,

needed other
• (betrayal trauma). This betrayal is thought to influence the way in

which the event is processed and remembered.

personality disorder 08/07/2023 60

Dissociative Identity Disorders
Patients with dissociative identity disorder can
present with acute forms of amnesia and fugue
episodes. These patients, however, are
 Characterized by a plethora of symptoms,

only some of which are usually found in

patients with dissociative amnesia.
 Report multiple forms of complex amnesia,

including recurrent blackouts, fugues,

unexplained possessions, and fluctuations in
skills, habits, and knowledge.

personality disorder 08/07/2023 61

DEPERSONALIZATION/DEREALIZATION DISORDER

The persistent or recurrent feeling of detachment

or estrangement from one’s self. The individual
may report feeling like an automaton or
 watching himself or herself in a movie

Derealization is somewhat related and refers to

feelings of unreality or of being detached from
one’s environment.
 The patient may describe his or her perception

of the outside world as lacking lucidity and

emotional coloring, as though dreaming

personality disorder 08/07/2023 62

DSM V

personality disorder 08/07/2023 63

DISSOCIATIVE FUGUE

 Dissociative fugue is described as sudden, unexpected travel

away from home or one’s customary place of daily activities,
with inability to recall some or all of one’s past.
 This is accompanied by confusion about personal identity or

even the assumption of a new identity. The disturbance is not

due to the direct physiological effects of a substance or a
general medical condition
The symptoms must cause clinically significant distress or
 impairment in social, occupational, or other important areas

of functioning.

personality disorder 08/07/2023 64

personality disorder 08/07/2023 65
Read other specified types from DSM
5…………….

personality disorder 08/07/2023 66

Referenses
 DSM 5,
 Kaplan and sadock’s synopsis of psychiatry,

11th edition,
 Kaplan and sadock’s comprehensive textbook

of psychiatry, 10th edition.

personality disorder 08/07/2023 67

Questions ???

personality disorder 08/07/2023 68

Thank You!!!

personality disorder 08/07/2023 69