PERSONALITY AND PERSONALITY

DISORDERS

DR E.U USUOYIBO
 OUTLINE
• Introduction
• Some Theories of Personality Development
• Dimensions and Types of Personality
• Personality disorders
-Classifications
-Epidemiology
-Aetiology
-Clinical features & Diagnosis
-Assessment
-Management
-Prognosis
• Conclusion
 WHAT IS PERSONALITY?

The word personality originated from the Latin word “persona”

“Persona” means mask worn by an actor to project a specific

character he represents.

Personality refer to enduring qualities of an individual that is

shown in his ways of behaving in a wide variety of circumstances.

It markedly influences people’s cognition, emotion, behaviours

and motivations.
 PERSONALITY TRAITS

Personality traits are characteristics and qualities

that help define a person as a unique individual.

They remain consistent across many situations

and circumstances.

They're often developed throughout life.

SOME THEORIES OF PERSONALITY DEVELOPMENT

Piaget’s Stages of Cognitive Development

Freud’s Structural Model of Personality

Freud’s Stages of Psychosexual Development

Erikson’s Stages of Psychosocial Development

Other theories
 Piaget’s Stages of Cognitive Development

According to Piaget, early cognitive

development is characterized by processes
based upon actions

Each stage is marked by children’s

understanding of the world, from exploration.
 4 Distinct Stages of Cognitive Development

Sensorimotor stage (0-2 years; object permanence, self-identity)

Preoperational stage (2-7yrs; symbolic thinking, animism, egocentric)

Concrete operational stage (7-11yrs; understand conservation but still

concrete)

Formal operational stage (>11yrs-adulthood; abstract thought)

 FREUD’S STRUCTURAL MODEL OF PERSONALITY

3 elements of personality- id , ego & superego

These works together to form complex human

behaviour

The balance between these 3 components is the key

to a healthy personality
 ID
Primary component of personality

present from birth, unconscious

source of all psychic energy, includes instinctive and

primitive behaviours
acts on pleasure principle which strives for immediate
gratification.
 EGO

ensures impulses of id are expressed in acceptable manner in reality

Functions in conscious, preconscious and unconscious mind

Based on reality principles

delays gratification
 SUPER EGO

Believed to emerge by the age of 5 yrs

Last personality component to emerge

Based on moral principle

Holds internalized moral standards & ideals from parents and the society

Suppreses unacceptable urges of id, makes ego act on standards instead of

reality principles
FREUD’S STAGES OF PSYCHOSEXUAL DEVELOPMENT

Stages of development of the libido (Oral –birth to 18 months,

Anal – 18 months to 3 yrs, Phallic – 3 to 6yrs, Latent- 6yrs to
puberty and Genital- puberty onward)

must be passed through successfully for healthy

personality development.

Fixation at a particular stage is considered to account for certain

features of adult personality e.g. fixation at the anal stage is
suggested to account for obsessional personality traits.
 ERIKSON’S STAGES OF PSYCHOSOCIAL DEVELOPMENT

Erik Erikson theory: Erikson formulated a

theory of human development that covers the
entire normal life span, divided into 8 stages.
 1. Trust versus mistrust (Oral Stage)

Occurs in infancy, from birth – 18 months

Children develop a sense of trust when they receive

care, affection and reliability from caregivers.

Lack of this sense of security leads to mistrust.

 2. Autonomy Versus Shame and Doubt (Anal Stage)

Occurs during early childhood, 2-3yrs

Children develop a sense of control over personal

skills as well as independence.

Successful completion of this stage leads to feelings

of autonomy while failure leads to shame and doubt.
 3. Initiative versus guilt

Occurs during (Phallic stage) preschool, 3-5 yrs

Children try to exert control over their environment.

Success leads to achieving a sense of purpose (i.e try to

control the environment) while failure leads to feeling guilty.
 4. Industry Versus Inferiority (Latency stage)

Occurs during school age, 6-11yrs

Children learn to cope with new social and academic

demands.

Success leads to a sense of competence while failure

leads to feelings of inferiority.
 5. Identity versus Role Confusion (Genital Stage)

Occurs during adolescence, 12-18 yrs

Development of a sense of self image and personal

identity occur at this stage (from the onset of puberty).

Success leads to a strong sense of self while failure

leads to role confusion.
 6. Intimacy Versus Isolation

Occurs during young adulthood, 19-40 years

Young adults explore loving relationship with others

at this stage.

Success leads to intimate relationship while failure

leads to isolation or loneliness.
 7. Generativity Versus Stagnation

Occurs during middle adulthood, 40-65 yrs

The adults establish things that outlast them like bringing up

children and developing positive change that benefit others.

Success leads to feelings of accomplishment while failure

leads to reduced involvement with the society.
 8. Integrity Versus Despair

Occurs in older adults, 65yrs – death

This stage is concerned with reflecting back on life

with a sense of fulfilment.

Success leads to feelings of wisdom while failure

leads to feelings of regret
 Other Theories

Adler’s theory: Adler coined the term

inferiority complex (a sense of inadequacy)

The Neo-Freudians (Fromm, Horney, and

Sullivan) emphasized social factors in
development.
 Dimensions and Types of Personality
Various attempts has been made to classify personality traits into personality
types, factors or dimensions.

Earliest attempt to categorize personality was by Hippocrates (450BC) and

Galen (190AD)

4 Ancient Greek ‘Temperaments’ proposed

• Sanguine: outgoing, easygoing, lively, carefree
• Melancholic: moody, anxious, pessimistic, sober, unsociable
• Choleric: restless, aggressive, impulsive, optimistic
• Phlegmatic: careful, thoughtful, controlled, reliable
 Dimensions and Types of Personality

Cattell (1957)
• Factor analysis: reduced thousands of trait names to 16
Personality Factors
• E.g. tense vs. relaxed, outgoing vs. reserved
• Measured using Cattell’s 16-PF a self-administered
questionnaire
 Dimensions and Types of Personality

Eysenck:
• Based on 3 major personality dimensions
• Extraversion – introversion (High extraversion scorers: sociable, lively,
assertive)
• Neuroticism – stability (High neuroticism scorers: anxious, prone to guilt, low
self-esteem, mood lability)
• Psychoticism – superego control (High psychoticism scorers: cold, lacking in
empathy, “tough minded”)
• Personality determined based on the relative position of the 3 key dimensions
of personality
• It is measured by Eysenck Personality Questionnaire
 Dimensions and Types of Personality

Norman, 1963; Costa & McCrae, 1992:

• The ‘Big Five’ Personality dimensions
• Extraversion – introversion: – tendency to be energetic and sociable
• Agreeableness – antagonism: – tendency to be warm and non-confrontational
• Conscientiousness – lack of direction: – tendency to be responsible and
organized
• Neuroticism – emotional stability: – tendency to be emotionally unstable
• Openness to experience – closed to experience: – tendency to value the
exploration of new feelings and ideas over traditionalism

Measured by the NEO Personality Inventory

 A Table of the Personality Dimensions Measured by the NEO Personality Inventory

Openness to
Neuroticism Extraversion Agreeableness Conscientiousness
experience
Anxiety Warmth Fantasy Trust Competence
Hostility Gregariousness Aesthetics Straightforwardness Orderliness
Depression Assertiveness Feelings Altruism Dutifulness
Self-consciousness Activity Level[ Adventurousness Compliance Achievement
Impulsiveness Excitement Seeking Ideas Modesty Self-Discipline
Vulnerability to Deliberation/
Positive Emotion Values Tendermindedness
Stress Cautiousness
 IMPORTANCE OF PERSONALITY IN PSYCHIATRY

Personality can predispose to psychiatric disorders by

modifying the response to stressful events.

Personality can account for unusual features in

psychiatric disorders.

Personality is an important determinant of an

individuals approach to treatment.
PERSONALITY
DISORDERS
 WHAT IS A PERSONALITY DISORDER?

According to WHO (1992), “ A personality

disorder is a chronic disturbance in ones relation
with self, others, and the environment that
results in distress or failure to fulfil social roles
and obligations”.
WHAT IS A PERSONALITY DISORDER? CONT’D

According to DSM-IV-TR by the APA, “PD is

defined as an enduring pattern of inner
experience and behaviour that deviates
markedly from the expectations of an individual’s
culture, is pervasive and inflexible, has an onset
in adolescence or early adulthood, is stable
overtime and leads to distress or impairment”.
DIFFERENCES BETWEEN PERSONALITY DISORDERS AND
OTHER MENTAL DISORDERS

The behaviours which define PD have been

present throughout adult life where as the
behaviours that define mental disorder differ
from the person’s previous behaviours.
 Grouping into clusters (DSM-IV)

In DSM-IV personality disorders are grouped into 3 clusters

Cluster A: (Odd-eccentric personality disorders) – paranoid,

schizoid, schizotypal.

Cluster B: (Dramatic – emotional –erratic personality

disorder) – Antisocial, Borderline, Histrionic, narcissistic.

Cluster C: (Anxious – fearful personality disorders) –

Avoidant, dependent, obsessive- compulsive.
 CLASSIFICATION OF PERSONALITY DISORDER

ICD-10 DSM-IV
Paranoid PD • Paranoid PD
Schizoid PD • Schizoid PD
(Schizotypal disorder) • Schizotypal PD
Dissocial PD Antisocial PD
Emotionally unstable • Borderline
-Impulsive type
- Borderline type
Histrionic • Histrionic
• Narcissistic

Anankastic • Obsessive-compulsive
Anxious (avoidant) • Avoidant
Dependent • Dependent
• Passive-aggressive
 EPIDEMIOLOGY

Approximate prevalence rates of the categories of PD in the gen pop (Casey, 2000)

Paranoid 0.5 - 3%

Schizoid 0.5 - 7%

Schizotypal 0.5 - 5%

Antisocial 2 - 3.5%

Borderline 1.5 - 2%
 EPIDEMIOLOGY CONT’D
Histrionic 2 - 3%

Narcissistic 0.5 - 1%

Avoidant 0.5 - 1%

Dependent 0.5 - 5%

Obsessive-compulsive 1 - 2%
 Gender Differences
Rate of PDs higher in male than female
• Paranoid, Antisocial, Narcissistic, Obsessive-compulsive, Schizoid,
Schizotypal PD

Rate of PDs equal in male and female

• Avoidant PD, Dependent PD

Rate of PD higher in female than male

• Borderline PD, Histrionic PD
 AETIOLOGY

Genetic factor – Twin study

Among monozygotic twin, concordance rate for PD was

several times higher than that among dizygotic twin

Monozygotic sets of twin reared apart are about as

similar as monozygotic sets reared together
 AETIOLOGY (CONT’D)

Adoptee studies

Adoptees separated at birth from parents who had persistent

antisocial behaviour, had higher rates of antisocial PD than
did adoptees whose parents were not antisocial
 AETIOLOGY (CONT’D)

Cerebral pathology & maturation

MRI studies show a lower prefrontal grey matter in the absence of gross
brain lesions in people with antisocial PD and this suggests prefrontal
dysfunction

Antisocial PD results from delay in the brain maturation

 AETIOLOGY

Neurotransmitters

Abnormalities in brain 5-HT neurotransmission have

been reported in pts with impulsive & aggressive
behaviour,
Low levels of the metabolite of 5-HT, 5-HIAA have been
found in CSF of subjects who committed acts of
unpremeditated violence.
 AETIOLOGY (CONT’D)
– Studies of body build and personality:
- Kretschmer (1936) described 3 types of body build:
- Pyknic (stocky and rounded)- cyclothymic
personality type (Sociable with variable
moods)
-athletic and
-asthenic (lean & narrow)- schizotypal
personality types (Cold, aloof and self sufficient)
 AETIOLOGY (CONT’D)

Developmental theories

Bowlby (1944, 1946) studied 44”juvenile thieves” and infer that

separation of a young child from the mother can lead to antisocial
behaviour and failure to form close relationships.

The association between separation and antisocial disorder in sons can

be influenced by marital disharmony
• Antisocial PD is commoner in:
• Men
• Younger people
• Those of low socio economic status
• Unmarried people
• The poorly educated
• Those living in urban areas
 CLINICAL FEATURES

PARANOID PD

Suspicious, secretive, mistrustful & jealous

Sensitive (sensitive ideas of reference),

argumentative

Resentful, bears grudges, engages in litigations, do not forgive real or perceived insults

Self-important
 SCHIZOID PD

Lack of interest in social relationships;

A tendency toward a solitary lifestyle;

Little interest in sexual experiences with another person;

Little interest in other, broader activities;

A lack of close friends other than first-degree relatives;

Indifference to praise or criticism;

Emotional coldness, detachment, and flattened affect.

 SCHIZOTYPAL PD

Socially anxious, inappropriate affective response

Cognitive & perceptual distortions

Eccentric behaviour, ideas of reference, suspicious ideas

Odd beliefs, magical thinking (e.g. belief in telepathy clairvoyance and mind reading)

Oddities of speech e.g unusual constructions, vagueness ; odd mannerisms, unusual choice of
clothing & awkward social behaviour

Appears to be related to schizophrenia

 ANTISOCIAL PD

Callous, lack of concern for the feelings of others

Irresponsible, impulsive & irritable

Lack guilt & remorse, low tolerance to frustration

Fail to accept responsibility (blame others)

Can’t maintain enduring relationships though have no difficulty in establishing them.

Superficial charm.

Their abnormal behaviour is made worse by abuse of alcohol or drugs

Deceitful & irresponsible about finances

 Emotionally Unstable PD
Impulsive Type

Impulsive

Liability to anger & violence

Unstable, capricious mood

Quarrelsome

Difficulty maintaining a course of action

(4 out of 5 valid for diagnosis)

 Emotionally Unstable PD Cont’d
Borderline type

Disturbed or uncertain self-image

Intense but unstable relationships

Make efforts to avoid abandonment

Recurrent threats or acts of self-harm

Chronic feelings of emptiness

(4 out of 5 valid for diagnosis)

 HISTRIONIC PD

Self-dramatization, emotional “blackmail”, angry scenes, demonstrative suicide attempts

Suggestible and easily influenced by others

Seek attention and excitement, crave new experiences

Short -lived enthusiasms

Shallow labile affect

Flirtatious & inappropriately seductive, but their sexual feelings are shallow and they may fail to reach orgasm
despite elaborate displays of passion
 HISTRIONIC PD CONT’D
Self-centred, appear vain, inconsiderate and demanding

Have marked capacity for self-deception

Over concerned with physical attractiveness and spend excessive amounts of time & money
on clothes, and personal grooming.

Are upset by even minor criticism of their appearance

Pathological liars & swindlers

 NARCISSISTIC PD

Grandiose sense of self-importance, boastful & pretentious

Preoccupied with fantasies of unlimited success, power, beauty, or intellectual brilliance

Believes himself special & expects others to admire him

Exploits others, lacks empathy

Arrogant disdainful & haughty and behave in a patronizing or condescending way

Envious, believes others envy him

 ANXIOUS (AVOIDANT) PD

Feels socially inferior

Preoccupied with the possibility of rejection, disapproval, or criticism and worry that they will be
embarrassed or ridiculed

Avoids involvement

Avoids risk

Avoids social activity, have few close friends

Persistently tense. Feel insecure & lack self-esteem

They are not emotionally cold however

 DEPENDENT PD

Allows others to take responsibility

Appear weak-willed and unduly compliant with the wish of others

Unwilling to make reasonable demands

Lack vigour & feels unable to care for self

Fear of being left to care for self

Needs excessive help to make everyday decisions

May drift down the scale and can be found among the long-term unemployed and the homeless
 ANANKASTIC PD

Preoccupied with details, rules, orders & schedules

Perfectionism that interferes with task completion
Scrupulous and overconscientious
Excessively concerned with productivity
Rigid & stubborn with high moral standards
Expects others to submit to his ways
Excessively pedantic & bound by convention
Excessively doubting & cautious
Sensitive to criticisms
 Personality Disorder in ICD-11

Personality disorder is characterized by problems in functioning of aspects of the self and/or

interpersonal dysfunction that have persisted over an extended period of time (e.g., 2 years or
more).

It manifests in patterns of cognition, emotional experience, emotional expression, and behaviour

that are maladaptive and is manifest across a range of personal and social situations.

The patterns of behaviour are not developmentally appropriate and cannot be explained primarily
by social or cultural factors.

It is associated with substantial distress or significant impairment in personal, family, social,

educational, occupational or other important areas of functioning.
 ICD-11 Diagnosis of Personality Disorders

Mild Personality Disorders

Moderate Personality Disorders

Severe Personality Disorders

Personality Disorders, Unspecified

 PROMINENT PERSONALITY TRAITS OR PATTERNS (ICD-11)

1. Negative affectivity in personality disorder or personality difficulty

2. Detachment in personality disorder or personality difficulty

3. Dissociality in personality disorder or personality difficulty

4. Anankastia in personality disorder or personality difficulty

5. Disinhibition in personality disorder or personality difficulty

6. Borderline pattern
Note: Each of these categories should be used in combination with a Personality
disorder category (Mild, Moderate, or Severe)
 Negative affectivity in personality disorder (NAPD) or personality difficulty

The key feature of NAPD is the tendency to

experience a broad range of negative emotions.

Common manifestations include emotional lability and

poor emotion regulation; negativistic attitudes; low
self-esteem and self-confidence; and mistrustfulness.
 Detachment in personality disorder (DPD) or personality difficulty

The core feature of DPD is the tendency to maintain

interpersonal and emotional distance.

Common manifestations include social detachment

(avoidance of social interactions, lack of friendships, and
avoidance of intimacy); and emotional detachment (reserve,
aloofness, and limited emotional expression and experience).
 Dissociality in personality disorder (DiPD) or personality difficulty

The core feature of DiPD is disregard for the rights and feelings of others.

1. Self-centeredness (e.g., sense of entitlement, expectation of others’

admiration, positive or negative attention-seeking behaviours, concern with
one's own needs, desires and comfort and not those of others).

2. Lack of empathy (i.e., hurt others, being deceptive, manipulative, and

exploitative of others, being mean and physically aggressive, callousness in
response to others' suffering, etc).
 Anankastia in personality disorder (APD) or personality difficulty

The core feature of APD is a narrow focus on one’s rigid standard of

perfection and of right and wrong, and on controlling one’s own and others’
behaviour and controlling situations to ensure conformity to these standards.

1. perfectionism (e.g., concern with social rules, obligations, and norms of

right and wrong, scrupulous attention to detail, rigid, hyper-scheduling,
emphasis on organization, orderliness, neatness etc).

2. Emotional and behavioral constraint (e.g., rigid control over emotional

expression, stubbornness and inflexibility, risk avoidance, etc).
 Disinhibition in personality disorder (DsPD) or personality difficulty

The core feature of DsPD is the tendency to act rashly

based on immediate external or internal stimuli (i.e.,
sensations, emotions, thoughts), without consideration of
potential negative consequences.

Common features include impulsivity, distractibility,

irresponsibility, recklessness, and lack of planning.
 Borderline Pattern

The Borderline pattern is applied to individuals whose

pattern of personality disturbance is defined by a pervasive
pattern of instability of interpersonal relationships, self-
image, and affects, and marked impulsivity

Common features are as described in emotionally unstable

personality disorder.
ASSESSMENT OF PERSONALITY DISORDERS(PD)
(i) A clinical disorder of PD should be based on an
accurate assessment of person’s enduring and pervasive
patterns of emotional expression, interpersonal
relationships, social functioning and views of self and
others when they are not suffering from another mental
disorder.

(ii) Informants are patient, clinical interview, previous

records (Medical, Prison, School, Social work),
independent account.
ASSESSMENT OF PERSONALITY DISORDERS(PD)

(iii) Explore the following aspects of personality:

interest & activities, relationship, mood/ emotions,
attitudes (religious, moral, and health), self concept,
coping with difficulties, specific characteristics or
traits .

(iv) Rule out differentials

INSTRUMENTS FOR ASSESSING PERSONALITY DISORDERS

OBJECTIVE INSTRUMENTS: MMPI (Minnesota

multiphasic personality inventory), EPQ (Eysenck
personality Questionnaire), Catell’s 16-PF e.t.c

PROJECTIVE INSTRUMENTS: Rorschach inkblot

test, Thematic apperception test, Sentence
Completion Test e.t.c
 RORSCHACH TEST.

Projective test developed by Hermann Rorschach.

Use of vague stimulus to reveal information about patients.

Ambiguous inkblots-5 black &white/5 colored-say to him “people interpret these in different
ways,I’d like to know what they mean to you”.

Record verbatim responses.

Exner scoring format.

RORSCHACH TEST.
THEMATIC APPERCEPTION TEST

Developed by Henry Murray and colleagues at Harvard

Psychological Clinic

Series of 30 pictures & one blank card used e.g. card 1

shows a young boy sitting at a table, looking at a violin.

Patient narrate personal story on it.

THEMATIC APPERCEPTION TEST
 MANAGEMENT
GOAL

To develop a therapeutic relationship with pts to help them receive the best
possible care.

The need to help the pt find a way of life that conflicts less with his
personality

A multidisciplinary approach is essential – psychiatrist, social workers,

clinical psychologists, primary care workers etc.
 PSYCHOLOGICAL TREATMENT

Supportive therapy
Psychoeducation
Counseling – problem solving counseling
Dynamic psychotherapy
Cognitive behaviour therapy (CBT)
Cognitive analytic therapy
Group therapy
Family therapy
Therapeutic community (TC)-antisocial PD
Dialectic behaviour therapy (DBT)-Borderline PD
Nidotherapy
 PHARMACOLOGICAL TREATMENT

Useful in treatment of individual symptoms rather than discrete PD

categories

Lithium - treatment of aggressive & assaultive behaviour

Anticonvulsants - treatment of mood instability, irritability & impulsivity

Antipsychotics - show moderate efficacy in treating the psychotic symptoms

sometimes experienced by patients with borderline PD
SSRI can be useful in the Rx of depressive symptoms associated with
borderline and avoidant PDs
 Treatment of specific PDs

Paranoid PD – do not engage well in

treatment because they are touchy
& suspicious

Schizoid PD – avoid close personal

contact & often drop out after a few
sessions of psychological treatment
Histrionic PD - These pts make many demands on
their carers. Demanding for help at unreasonable
times, seductive behaviour & threats of self-harm
can present serious challenge for treatment.

Behaviour modification and clear limit setting

may be beneficial. Medication has little role unless
there is a co-existing depressive d/o
 DIALECTICAL BEHAVIOURAL THERAPY

This is a form of cognitive therapy developed by Marshal

Linehan and originally used in the treatment of repeatedly
parasuicidal female patients with borderline PD.

Emotionally unstable (Borderline) PD may benefit from

this treatment.
 THERAPEUTIC COMMUNITY

A form of treatment developed by Maxwell Jones, in which the

environment setting becomes the core therapy, where behaviour can
be challenged & modified through group interaction and interpersonal
understanding

Patients with antisocial PD can benefit from this treatment.

 NIDOTHERAPY

Nidus (latin) – Nest.

Nest therapy

Include the modification of the environment to minimize the

impact of any PD on the individual or on society
 PROGNOSIS

PDs are persistent disorders so little change

would be expected with time.

The order of favourable prognosis- cluster C >

Cluster B >Cluster A
 CONCLUSION
PD are chronic, common and highly disabling
disorders.

Thorough assessment is required to make

appropriate diagnosis.

Though not easy to treat, painstaking effort and

empathetic multidisciplinary care is highly beneficial.