Personality Disorders PDF

Personality Disorders  Personality Disorders A heterogeneous group of disorders defined by longstanding pattern of behavior and inner experiences that deviate from the expectations of their culture, is pervasive and inflexible, has an onset in adolescence or early adulthoo...

Personality Disorders  Personality Disorders A heterogeneous group of disorders defined by longstanding pattern of behavior and inner experiences that deviate from the expectations of their culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. Manifested in two or more of the following areas: cognition, emotion, relationship, impulse control. As a general rule, personality disorders are representative of long-term functioning and are not limited to episodes of illness.  Personality Disorders Personality disorders can cause enormous problems for individuals and society and are frequently associated with impaired social, interpersonal, and occupational adjustment. Family life, marriages, and academic and work performance suffer. Rates of unemployment, homelessness, divorce and separation, domestic violence, and substance misuse are high. These disorders also are associated with increased rates of health care utilization (e.g., emergency department visits, hospitalizations) and excessive rates of traumatic accidents. As a group, individuals with personality disorders are at risk for early death from suicide or accidents. Nearly all persons with a personality disorder have one or more comorbid mental disorders, with major depression being the most frequent. Other mood, anxiety, substance use, and eating disorders are all commonly diagnosed in persons with a personality disorder. Comorbidity among the personality disorders is also very common, with persons with one disorder frequently meeting criteria for another. As mentioned earlier, few persons have a “pure” case in which they meet criteria for only one personality disorder.  Personality Disorders/Epidemiology  Epidemiological surveys show that personality disorders are common in the general population, with between 9% and 16% of respondents meeting criteria for one or more personality disorders.  The prevalence is greater in psychiatric samples. In some studies, 30%–50% of outpatients have a personality disorder, although the frequency and types differ depending on the mental disorders assessed.  The frequency of specific personality disorder differs by gender. Antisocial personality disorder occurs more frequently in men Whereas borderline personality disorder, histrionic personality disorder, and dependent personality disorder are more frequent in women. Others have a fairly equal gender distribution (schizoid, schizotypal, and obsessive compulsive personality disorders).  Younger persons are at greater risk for a personality disorder than older individuals. Personality disorders tend to have an onset in adolescence and are established by young adulthood.  If a personality disorder is to be diagnosed in a person younger than age 18, DSM-5 requires that the maladaptive personality features be present for at least 1 year. The exception is antisocial personality disorder, in which an age requirement is specified (18 years).  Personality pathology in childhood or adolescence is often predictive of adult maladjustment and the development of a personality disorder.  Personality Disorders There is 10 personality disorders which are classified into 3 groups: Cluster A: odd or eccentric behavior or bizarre thinking, including: paranoid, schizoid, schizotypal personality disorders. Cluster B: dramatic or emotional behaviors, including: antisocial, borderline, histrionic, narcissistic personality disorders. Cluster C: anxious of fearful behaviors, including: avoidant, dependant, obsessive compulsive personality disorders.  Paranoid personality disorder A. Pervasive distrust and suspiciousness of others , beginning early adulthood, as indicated by 4 or more of the following: 1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them. 2. Preoccupied with unjustified doubts about the loyalty or trustworthiness of others. 3. Reluctant to confide others because of unwarranted fear that the information will be used against them.  Paranoid personality disorder 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 their character or reputation that are not apparent to others and is quick to react angrily or to counterattack. 7.Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner  Paranoid personality disorder B. Doesn't occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, or another psychotic disorder and is not due to the direct physiological effects of a general medical condition.  Paranoid personality disorder Other features: Difficult to have close relation, fear love, interest in electronics. They are rigid. Less impairment in social and occupational functioning. Comorbid with schizotypal, borderline, and avoidant personality disorders.  Paranoid personality disorder Etiology: fear of shame, homosexual underlying conflict. Treatment: respect and trust, and set limit in threatening situations.  Schizoid personality Disorder A. Pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood, as indicated by 4 or more of the following: 1. Neither desires nor enjoys close relationships, including being part of a family. 2. Almost always chooses solitary activities that don’t include interaction with others (mechanical: computer or abstract thinking: math games.  Schizoid personality Disorder 3.Has little, if any, interest in having sexual experiences with another person (often don’t marry). 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 activity (smile, nod, anger, joy).  Schizoid personality Disorder B. Does not occur during the course of schizophrenia, mood disorder with Psychotic Features, another Psychotic Disorder and is not due to the direct physiological effects of a general medical condition. Other information: M more than F Uncommon in clinical setting, long lasting disorders, have successful work history. Etiology: culture, family interactive style, genetics.  Schizotypal personality disorder Perception, thinking and communication are disturbed. A. Pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and, as indicated by 5 or more of the following: 1.ideas of reference: incorrect interpretation of events as having unusual meaning (excluding delusions of reference). 2.odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (special powers to sense events before they happen or read others thoughts).  Schizotypal personality disorder 3.Unusual perceptual experiences, including bodily illusions. 4. Odd thinking and speech. 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.  Schizotypal personality disorder B. Does not occur during the course of schizophrenia, mood disorders with psychotic features, another Psychotic Disorder, or a pervasive developmental disorder.  Schizotypal personality disorder Other information: Seek treatment for depression, anxiety and another symptoms rather than for personality disorder. Causes for cluster A: genetics. Patients with schizophrenia are at increased risk for these personality disorders especially schizotypal.  Antisocial personality disorder A. Pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by 3or more of the following: 1. Failure to conform to social norms with respect to lawful behaviors. 2. Deceitfulness (repeated lying). 3. Impulsivity or failure to plan ahead (take decisions without thinking about consequences).  Antisocial personality disorder 4.Irritability and aggressiveness, as indicated by repeated physical fights or assaults. 5. Reckless disregard for safety of self or others (driving, accidents). 6.Consistent irresponsibility (repeated failure to sustain consistent work behavior or honor financial obligations). 7. Lack of remorse (being indifferent to or rationalizing having hurt, mistreated, or stolen from another).  Antisocial personality disorder 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 of antisocial behavior is not during the course of schizophrenia or a manic episode.  Antisocial personality disorder Other information: It occurs in low socioeconomic class and urban settings. M>F It is chronic disorder and becomes less evident as individual grows older.  Etiology Genetic factors. Social factors: especially in first 5 years of life. Family environment: high negativity, low warmth, poverty, exposure to violence, parenting pattern, child parent relationship (trust versus autonomy). Emotion: they do not experience negative emotions such as fear or anxiety when they encounter antisocial situation. Also punishment doesn’t arouse strong emotion or inhibit antisocial behaviors.  Borderline personality disorder pervasive pattern of instability of interpersonal relationships, self-image, affects, and marked impulsivity beginning by early adulthood as indicated by 5 or more of the following: 1. frantic efforts to avoid real or imagined abandonment (panic if somebody important come late or cancel an apointment) because it implies they are bad or intolerance of being alone. 2.unstable and intense interpersonal relationships (extremes of idealization and devaluation). Borderline personality disorder 3.identity disturbance, 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). 5.recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior 6. affective instability. 7. chronic feelings of emptiness.  Borderline personality disorder 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 (depersonalization) which last for minutes or hours (remission occurs as the caregivers return their nurturance).  Borderline personality disorder Other information: Undermining themselves at the moment his goal is about to be realized (drop out of school just before graduation, destroying relation when it is clear it could last). Develop psychotic symptoms (hallucination, ideas of reference) during stress. Common, very hard to treat and associated with suicide.  Etiology Neurobiological factors: genetics, decrease function of serotonin system. Social factors: physical and sexual abuse, neglect, hostile conflict, and parental loss or separation. Object-relation theory: adverse childhood experiences when child fail to integrate loving and unloving aspects of the people who are close to them because of their parents provide love and support inconsistently so they develop insecure ego and BPD. Common in their personal history.  Etiology During their 30s-40s, the majority of the individual attain greater stability in their relationship. By age 40, most people seem no longer meet the diagnostic criteria comorbid AXIS I anxiety disorder (esp. PTSD), mood disorder.  Histrionic personality disorder (hysterical personality) pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood as indicated by 5 or more of the following: 1. uncomfortable in situations in which he or she is not the center of attention, so they may create stores or scene, gift, providing new symptoms each visit to attract attention. 2. interaction with others by inappropriate sexually seductive or provocative behavior.  Histrionic personality disorder (hysterical personality) 3.displays rapidly shifting and shallow expression of emotions. 4. uses physical appearance to draw attention to self (spend money on cloths, hair color, and grooming or complains about photos). 5.style of speech that is excessively impressionistic and lacking in detail (this person is good without ability to mention the reason). 6.shows self-dramatization, theatricality, and exaggerated expression of emotion (excessive public display of emotions).  Histrionic personality disorder (hysterical personality) 7.is suggestible, (easily influenced by others or circumstances). 8.considers relationships to be more intimate than they actually are (calling the doctor by his/her name or use my dear, dear friend). Other information: Over reaction to minor events, egocentric, demanding. They have impaired relation with the same sex. Initiate job with great enthusiasm but their interest lag quickly. Ignore long relation and start new relation. Don’t exhibit feeling of emptiness, or identity diffusion.  Histrionic personality disorder (hysterical personality) F>M Etiology: childhood traumatic experiences. Psychoanalytic theory: it occurs as a result of parental seductiveness especially fathers seductive behavior toward his daughter. also the patients were raised in a family in which parents talk about sex as dirty yet behaved as though it was existing and desirable which create conflict.  Narcissistic personality disorder pervasive pattern of grandiosity, need for admiration, and lack of empathy, beginning by early adulthood as indicated by 5 or more of the following: 1. has grandiose sense of self-importance (e.g., exaggerates achievements and talents). 2. preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.  Narcissistic personality disorder 3. believes that they are special and unique. 4. requires excessive admiration. 5. has a sense of entitlement. 6. interpersonally exploitative. 7. lacks empathy. 8.often envious of others or believes that others are envious of him or her. 9.shows arrogant, haughty behaviors or attitudes.  Etiology Self psychology model: When the parent respond to the child with respect, warmth and empathy, they endow their child with normal sense of self worth. When they don’t do that, low self esteem will develop and the child will have a problem in accepting their own shortcoming so they try to bolster their sense of self worth through unending quests for love and approval from others.  Etiology Social cognitive model: Patient has fragile self esteem and interpersonal interaction is important for bolstering self esteem rather than closeness or warmth. They show cognitive bias to maintain grandiose self beliefs (brag a lot when success or denigrate the other person when fail).  Avoidant personality disorder pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood as indicated by 4 or more of the following: 1. avoid occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection.  Avoidant personality disorder 2.unwilling to get involved with people unless certain of being liked. 3.shows restraint within intimate relationships because of the fear of being shamed. 4.preoccupied with being criticized or rejected in social situations. 5.inhibited in new interpersonal situations because of feelings of inadequacy.  Avoidant personality disorder 6.views self as socially inept, personally unappealing, or inferior to others. 7.reluctant to take personal risks or to engage in any new activities because they may prove embarrassing (cancel job interview for fear of being embarrassed by not dressing appropriately).  Avoidant personality disorder Other notes: It is often diagnosed with dependent personality disorders or borderline personality disorder. M=F Etiology: genetics or influence of environment in which the child is taught to fear situation or people who are harmful or stranger.  Dependent personality disorder pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and as indicated by 5 or more of the following: 1. has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.  Dependent personality disorder 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. 4.has difficulty initiating projects or doing things on their own. 5.goes to excessive lengths to obtain nurturance and support from others (volunteering to do things that are unpleasant).  Dependent personality disorder 6.feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for theirselves. 7.urgently seeks another relationship as a source of care and support when a close relationship ends. 8.unrealistically preoccupied with fears of being left to take care of himself or herself.  Dependent personality disorder F>M Chronic course. Etiology: Genetic, overprotective and authoritarian parenting style that prevent the development of feeling of self efficiency. Attachment problem: child's separation from adult lead to anger and stress and feel secure in the presence of figure of security, failed in this process lead to this disorders. Psychoanalysis: oral stage and satisfaction from dependency  Obsessive-Compulsive personality disorder pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood as indicated by 4 or more of the following: 1. preoccupied with details, rules, lists, order, organization so that the major point of the activity is lost and repeatedly checking for mistakes.  Obsessive-Compulsive personality disorder 2.shows perfectionism that interferes with task completion (restrict standard so the project doesn't finished). 3.excessively devoted to work and productivity to the exclusion of leisure activities and friendships. 4.inflexible about matters of morality, ethics, or values. 5. unable to discard worn-out or worthless object. Obsessive-Compulsive personality disorder 6.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. 8. shows rigidity and stubbornness.  Obsessive-Compulsive personality disorder Other notes: Time is poorly managed and leave most important task to last moment, deadline is missed. Etiology: genetics. Freud: fixation at anal stage (2-4 years) and fear loss of control which is handled by overcompensation. Ericson theory: autonomy verses shame (expression of direct anger may be bring about shame or criticism so attention to details is done to avoid parents, criticism and get affection so the child learn to distant self from unmet affection need by obsessive defense and displacing anger to more neutral object.  Treatment Medication Avoidant: antidepressant, antianxiety to reduce social anxiety (phobia), group therapy to reduce sensitivity to rejection, social skills training. Schizotypal: antipsychotic drugs (for schizophrenia), psychotherapy, group and individual therapy, psychodynamic (alter pts view of childhood problem).  Treatment CBT: break personality disorders into set of problems (e.g paranoid or avoidant disorder: sensitive to criticism: so treated by social skills training, systematic desensitization, identify and challenge negative thought. Hysterical: psychoanalysis. Naracisstic: psychoanalysis and view grandiosity as defense mechanism so support and show empathy with the patients.  Treatment Antisocial: self help group than jails or psychiatric unit or one to one therapy, firm limit, halfway house, treat addiction, provide alternative method to express anxiety (not only to stop action). Dependent personality: behavior therapy (assertiveness training). Obsessive-compulsive: patients know they have a problem and seek treatment, group and individual therapy.  Treatment of borderline personality disorder The most difficult problem to deal with as the pts tend to show their interpersonal problem toward the therapists (distrust him so it affects the therapeutic relation) or demanding special attention from the therapists, refuse to keep appointment next, beg the therapist for understanding and support. Suicide is a serious risk but is difficult to therapist to judge pt behavior (call at 2 am, seek attention or suicide) so hospitalization may be nedded.  Treatment of borderline personality disorder Drugs: Antidepressant (Fluvoxamine, Sertraline); Antipsychotic (Olanzapine, Quetiapine), Lithium reduces anger, irritability and suicidility. Antiseizure that is use to treat bipolar disorder. Object relation psychotherapy: to strength pts weak ego so that he/she stop splitting (seeing every thing to a simple good or bad).  Treatment of borderline personality disorder Dialectical behavior therapy include either: Therapists accept pts and help them to change. The pts realize that splitting the world into good (antithesis) and bad (thesis) isn't necessary and develop synthesis of both.  Treatment of borderline personality disorder Provide group and individual therapy, involving 4 stages: Identify dangerous impulsive behavior. Learning to control extreme emotionality and tolerate distress. Improving self-esteem and relations. Promote connectedness and happiness.  General Rules For diagnosis: out organic causation, get objective records from school, employment, hospitals, investigate the repetition of the behaviors in the past. Defence mechanism: which are healthy for these patients to help them to reduce anxiety and depression including fantasy (schizoid and therapist should be quiet and reassuring without criticism), dissociation (histrionic: deny to ventilate their anxiety), isolation (compulsive: request for control which annoying the therapist).  General Rules Projection (attribute their feelings to others so maintain formal distance, strict honesty are helpful, dot agree with the patient but ask if they can agree to disagree, use counter projection techniques: give the patients full credit for their feeling and perceptions, but do not dispute their complains, nor reinforce them.