Personality Disorders Master Class PDF

Personality Disorders Master Class David Montero MD, Psychotherapist  Objectives Identify the psychopathology, clinical features, and diagnosis of each Personality Disorder: A. Cluster A (Paranoid PD. Schizoid PD. Schizotypal PDD) B. Cluster B...

Personality Disorders Master Class David Montero MD, Psychotherapist  Objectives Identify the psychopathology, clinical features, and diagnosis of each Personality Disorder: A. Cluster A (Paranoid PD. Schizoid PD. Schizotypal PDD) B. Cluster B (Antisocial PD. Borderline PD. Histrionic PD. Narcissistic PD.) C. Cluster C (Avoidant, PD. Obsessive Compulsive PD., Dependent PD.) D. Personality Disorder due to Medical Condition  Personality Personality is the enduring set of behaviors, attitudes, and inner experiences that define how we think, feel, and act. Typically forming in adolescence and lasting into adulthood. It shapes our interactions, stress responses, self-perception, and how we relate to others, forming the core of our identity. Personality also represents our unique adaptation to changing environments, influenced by both genetic and environmental factors. General Personality Disorder Personality Disorders A personality disorder is defined by a lasting pattern of inner experience and behavior that deviates significantly from cultural norms and affects cognition, emotions, relationships, or impulse control. This pattern is inflexible, pervasive ACROSS VARIOUS SITUATIONS, causes significant distress or functional impairment, and can be traced back to adolescence or early adulthood. It cannot be explained by other mental disorders or substance effects. Requires evaluating long-term behavior patterns, distinguishing these traits from responses to temporary stressors or mental states Often using input from multiple interviews and external sources, as individuals may not see their traits as problematic (ego-syntonic). Diagnosis of a personality disorder typically occurs after the age of 18, as personality tends to stabilize in the early 20s.  Egosyntonic: Refers to feelings, thoughts, and/or behaviors that are acceptable to the Personality Disorders self; that are consistent with one’s fundamental personality. Resistance to change: Personality Disorders may involve egosyntonic beliefs such as perfectionism seen in Obsessive Compulsive Personality Disorder Unlike other psychiatric disorders, individuals with personality disorders often resist seeking help and may deny their issues. Symptoms are typically: Ego-syntonic, meaning they align with the person's ego. Egodystonic (Their behavior creates no distress for them even though it Refers to feelings, thoughts, and/or behaviors that are distressing, may adversely affect others.) unacceptable, or inconsistent with one’s self-concept Alloplastic, where adaptation involves altering the external environment rather than self-change. Psychotherapy helps create autoplastic change They may also be reluctant to engage in a treatment process; Alloplastic: because their defenses are essential to controlling Tries to change all the people unpleasant affects, they are not interested in surrendering around them them. This lack of insight into maladaptive behavior and resistance to acknowledge disturbances from symptoms can lead to apparent disinterest in treatment and a perceived resistance to recovery. Autoplastic: Patients with personality disorders Changes self to cope with the avoid psychotherapy like Superman environment avoids kryptonite, seeing it as a Psychotherapy helps create this weakness that makes them feel change. vulnerable and exposed.  Personality Disorders Defense Personality Defense mechanisms help individuals cope with intense Mechanism Disorder (Over-reliance) emotions like anxiety, depression, anger, shame, and guilt. Projection Paranoid PD “Effective” defenses can reduce symptoms, often making Splitting Borderline PD patients resistant to change. Acting Out Borderline PD However, over-reliance on defense mechanisms can Antisocial PD contribute to developing a personality disorder. Regression Dependent PD Psychodynamic clinicians associate specific defense Idealization Many of them mechanisms with each personality disorder; for instance, projection is linked to paranoid personality disorder. Passive Borderline PD Aggression Management thus involves identifying and addressing these defenses, often through a personalized blend of therapeutic approaches.  Personality Disorders Epidemiology & Comorbidity: In specific settings, like primary care or psychiatric facilities, the Personality disorders are fairly common, affecting 10-20% of the prevalence varies, with approximately 7% in primary care, 40% general population, with higher rates among psychiatric in psychiatric outpatients, and up to 50% in psychiatric patients, where it can be as high as 50%. inpatients meeting criteria for personality disorders. They often coexist with psychiatric disorders including Additionally, a significant portion of prisoners, up to 75%, also substance use disorders, suicidal behaviors, depression, bipolar have personality disorders, with antisocial personality disorder disorder, impulse-control disorders, eating disorders, and being the most common. anxiety disorders.  Personality Disorders – Categorial Model Researchers have long sought a classification system for personality disorders that balances simplicity and depth. However, this model has been criticized for high rates of comorbidity, variation within disorders, and frequent DSM-5 retains a traditional categorical model, treating diagnoses of "unspecified" personality disorder. personality disorders as distinct syndromes, which is straightforward and widely used. Despite these critiques, the categorical model remains the The categorial model categorizes personality disorders into official approach in DSM-5. three clusters: A.B.C. It's common for individuals to exhibit traits that span multiple personality disorders, and when criteria for more than one disorder are met, clinicians should diagnose each disorder accordingly. Cluster A – Odd or eccentric Encompasses odd and aloof features, including paranoid, schizoid, and schizotypal personality disorders. Cluster B – Dramatical, Emotional, Erratic Comprises personality disorders with dramatic, impulsive, exploitative, and erratic traits, such as borderline, antisocial, narcissistic, and histrionic personality disorders. Cluster C – Anxious or Fearful Includes personality disorders characterized by anxious and fearful features, including avoidant, dependent, and obsessive-compulsive personality disorders  Cluster A – Odd, Eccentric. Cluster A Personality Disorders. (Paranoid. Schizoid. Schizotypal) Known as Odd or Eccentric. Are characterized by distorted perceptions, limited social interactions, and behaviors seen as peculiar but not psychotic, as logical thinking is intact. These traits can be premorbid indicators for the development of psychotic disorders later in life such as schizophrenia. Diagnosis should not be made if the patient shows psychiatric symptoms such as delusions or hallucinations.  Paranoid Personality Disorder Paranoid personality disorder is characterized by excessive suspiciousness and distrust of others, leading to a pervasive tendency to interpret others' actions as malevolent or threatening without evidence. Individuals with this disorder believe others will exploit or deceive them, scrutinizing friend’s loyalty, and fearing betrayal, which often prevents close relationships. They interpret harmless remarks as insults or threats, persistently hold grudges, and react with hostility to perceived slights. They project their own emotions onto others, attributing impulses and thoughts they cannot accept in themselves to those around them. This projection can be seen as pathological jealousy, suspecting infidelity without justification, and exerting control in relationships. This diagnosis excludes patterns due to psychotic disorders or medical conditions.  Paranoid personality disorder may be first apparent in childhood and adolescence with solitariness, poor peer relationships, social anxiety, underachievement in school, and interpersonal hypersensitivity. Paranoid Personality Disorder Adolescent onset of paranoid personality disorder is associated with a During psychiatric examination, individuals with paranoid personality disorder often present in a formal and severe manner. prior history of childhood maltreatment. Appear confused about needing psychiatric help and continuously Diagnosis occurs during adulthood. scan for threats during the interview. Exhibit muscular tension, an inability to relax. Though their speech is goal-oriented and logical, it may reveal projection, prejudice, and ideas of reference. Paranoid personality disorder can be a premorbid antecedent of delusional disorder, and schizophrenia. Lifelong difficulties include issues in work and relationships, with complications such as brief reactive psychosis, especially under stress. Example: I do not trust you, why are you asking me those questions; what will you do with my information? If my information gets revealed I will hold you responsible.  Schizoid Personality Disorder The essential feature of schizoid personality disorder is a pervasive pattern of detachment from social relationships and a limited expression of emotions in interpersonal contexts. Individuals with this disorder typically lack a desire for intimacy and seem indifferent to forming close relationships, preferring solitary activities and showing little interest in sexual experiences. They often have reduced pleasure in sensory or interpersonal experiences and usually have no close friends, apart from possibly a first-degree relative. These individuals are generally indifferent to others' approval or criticism, may not respond appropriately to social cues, and appear socially inept or self-absorbed. They display a bland exterior with little emotional reactivity and claim to experience few strong emotions. However, in rare situations where they feel comfortable, they may acknowledge painful feelings related to social interactions. Diagnosis of schizoid personality disorder should not occur if the behaviors occur exclusively during episodes of schizophrenia, bipolar disorder with psychotic features, or other psychotic disorders, or if attributable to neurological or medical conditions. Final Fantasy VIII (1999)  Schizoid personality disorder may be first apparent in childhood and adolescence with solitariness, poor peer relationships, and Schizoid Personality Disorder underachievement in school, which mark these children or adolescents as different and make them subject to teasing. Diagnosis occurs in adulthood. On psychiatric examination they usually avoid eye contact and display a limited range of emotions. Their communication style is straightforward and to the point, typically lacking spontaneity or humor, and they may exhibit peculiar speech patterns or a strong interest in abstract concepts. These individuals tend to be reserved and show little interest in engaging with others or participating in typical social activities, leading to solitary lifestyles and unconventional job choices. They often prefer solitary pursuits and personal interests, struggling to form meaningful relationships and favoring fantasy over real-life experiences, particularly in terms of sexuality. Despite their detached demeanor, individuals with schizoid personality disorder generally retain intact sensory and memory functions, and their cognitive abilities are usually preserved, as evidenced by their capacity for abstract thinking and interpretation of proverbs. The condition can lead to severe social relations and occupational issues involving interpersonal involvement. It is long-lasting but not always lifelong, sometimes serving as a premorbid antecedent to delusional disorder, schizophrenia, or, rarely, major depression. Example: I prefer to be alone; people just complicate Common complications include brief reactive psychosis under stress. things  Schizotypal Personality Disorder The essential feature of schizotypal personality disorder is a pervasive pattern of social and interpersonal deficits, characterized by acute discomfort with, and reduced capacity for, close relationships, as well as cognitive or perceptual distortions and eccentric behaviors. Individuals with this disorder often experience ideas of reference, incorrectly interpreting casual incidents as having unusual meaning for them, but these differ from delusions of reference, which are held with strong conviction. They may also display superstitious beliefs or a preoccupation with paranormal phenomena. Some believe they possess special powers, such as sensing future events or controlling others through magical thinking. Perceptual alterations, such as sensing the presence of another person or hearing voices, may occur. Their speech can be unusual, with idiosyncratic phrasing and loose or vague constructions, and responses may be either overly concrete or abstract. Additionally, individuals may exhibit suspiciousness and paranoid ideation, believing others are undermining them. These individuals often struggle with interpersonal affect and cues, appearing stiff or inappropriate in social interactions.  May be first apparent in childhood and adolescence with solitariness, poor peer relationships, social anxiety, underachievement in school, Schizotypal Personality Disorder hypersensitivity, peculiar thoughts and language, and bizarre fantasies. These children may appear “odd” or “eccentric” and attract teasing. Their eccentric behavior may include unkempt clothing and neglecting Diagnosis occurs in adulthood. social conventions, such as avoiding eye contact. Although they may express unhappiness about their lack of relationships, they typically show a decreased desire for intimacy, resulting in few close friends, if any, aside from first-degree relatives. Some maintain stability, marry, and work despite oddities. Social situations are anxiety-provoking, especially with unfamiliar individuals, and their discomfort does not diminish over time due to a pervasive suspicion of others’ motivations. It is important to note that schizotypal personality disorder should not be diagnosed if these behaviors occur exclusively during schizophrenia, bipolar or depressive disorders with psychotic features, other psychotic disorders, or autism spectrum disorder. Potential progression to schizophreniform disorder, or schizophrenia. Complications include transient psychotic episodes under stress. Example: I sense energies beyond sight, a world of vibrations unseen by ordinary eyes Example: My intuition whispers truths from realms unknown, guiding me through the unseen Example: I believe in the unseen threads that connect us, weaving a tapestry of energies and possibilities Example: There's a veil between realities, and I glimpse through it, catching echoes of what's to come Example: The universe speaks in whispers, and I listen, attuned to the subtle signs and messages it sends Cluster B – Dramatic, Emotional, Erratic Cluster B Personality Disorders. (Antisocial. Borderline Personality Disorder. Histrionic. Narcissistic) Are linked to mood disorders such as depression and bipolar disorder. Additionally, they are associated with substance abuse disorders stemming from difficulties in impulse control. Chaotic interpersonal relationships consistently play a significant role within this cluster. Antisocial Personality Disorder The essential feature of antisocial personality disorder is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood. This pattern has also been referred to as psychopathy, sociopathy, or dissocial personality disorder. Because deceit and manipulation are central features of antisocial personality disorder, it may be beneficial to integrate information collected from collateral sources. Individuals with antisocial personality disorder (ASPD) often display a lack of empathy and exhibit callousness, cynicism, and contempt for the feelings and rights of others. Often engaging in illegal or socially unacceptable behaviors such as lying, theft, substance use, and aggression. They may have an inflated sense of self-importance, believing that ordinary work is beneath them, and can come across as excessively self- assured or arrogant. Some may possess superficial charm and articulate speech, using jargon to impress others, deceiving others for personal gain without remorse. These individuals are often irresponsible and exploitative in their sexual relationships, frequently having numerous partners without sustaining monogamous commitments. Antisocial Personality Disorder Antisocial Personality Disorder As parents, they may neglect their children's needs, resulting in malnutrition or inadequate care. ASPD is three times more common in men than women. Women with the disorder are more likely to have experienced adverse experiences such as sexual abuse. The disorder is more prevalent among first-degree relatives of affected individuals and is often associated with low socioeconomic status and urban environments. Clinical presentations vary, with men typically exhibiting more irritability and aggression, while women may show a higher prevalence of mood and anxiety disorders. Factors such as childhood abuse, unstable parenting, and inconsistent discipline may increase the likelihood of developing ASPD from conduct disorder. On psychiatric examination despite appearing composed and credible in interviews they may harbor underlying tension, hostility, and rage. ASPD cannot be diagnosed in individuals under 18 unless there is evidence of conduct disorder before age 15, and the risk of developing ASPD is heightened in those with childhood conduct disorder and Enuresis attention-deficit/hyperactivity disorder. The course of ASPD is chronic but may become less evident with age as criminal behavior typically decreases, symptoms decrease particularly by MACDONALD the age of 40, however, irritability, impulsiveness, and detachment TRIAD persist. They have an increased risk for impulse control disorders and substance use disorders. Cruelty to Complications include dysphoria, tension, low boredom tolerance, and Pyromania Animals premature violent death.  Borderline Personality Disorder Patients with borderline personality disorder stand on the border between neurosis and psychosis, and they have extraordinarily unstable affect, mood, behavior, object relations, and self-image. Differentiation of Personality Organization (based on Kernberg, 1984; Caligor et al. 2007)  Borderline Personality Disorder Borderline personality disorder (BPD) is characterized by pervasive instability in relationships, self-image, emotions, and impulsivity, these often resulting in chaotic and tumultuous lives. Individuals with BPD often have an INTENSE FEAR OF ABANDONMENT, reacting with panic, anger, or despair to real or perceived separations. Individuals with BPD are impulsive, potentially engaging in self-destructive behaviors like reckless driving, unsafe sex, or substance abuse. They may engage in frantic self-destructive behaviors to avoid abandonment, including self-harm or suicidal actions to cope with overwhelming emotions, or to manipulate or to seek attention. Their relationships are typically unstable, with rapid shifts from idealization to devaluation of others, they have difficulty maintaining stable interpersonal relationships due to their tendency to see others as either all good or all bad, (Splitting) They may feel intense disappointment when someone they idolized fails to meet their needs. A disturbed sense of identity is also common, leading to unpredictable shifts in self- image and making it difficult to maintain a consistent identity. Chronic feelings of emptiness and intense, short-lived mood swings—ranging from dysphoria and irritability to panic—are common, often triggered by interpersonal stress. Anger outbursts are frequent and are usually followed by feelings of shame or guilt. During extreme stress, they may experience transient paranoid thoughts (micropsychosis) or dissociative symptoms, WHICH OFTEN RESOLVE WHEN THEY FEEL REASSURED BY OTHERS.  Borderline Personality Disorder (BPD) can develop as early as adolescence, though it traditionally has been viewed as an adult-onset disorder. Adolescents as young as age 12 can meet full criteria for the disorder. Early trauma, especially emotional and physical abuse, is frequently seen in the histories of people with BPD, though sexual abuse is linked more to severity than the development of BPD itself. Symptoms often decrease by a person’s 30s or 40s, with impulsive behaviors remitting sooner than emotional symptoms. However, full recovery, marked by stable symptom remission and improved psychosocial functioning, is challenging and less common. Individuals with BPD may have a pattern of undermining themselves at the moment a goal is about to be realized (e.g., dropping out of school just before graduation; regressing severely after a discussion of how well therapy is going; destroying a good relationship just when the relationship could last). Often feel more secure with transitional objects (pets or inanimate possessions) than interpersonal relationships. than people. Suicide risk is elevated, particularly with co-occurring depression or substance use, but accidental deaths are even more common. BPD commonly co-occurs with mood disorders (depression, bipolar), substance use disorders, anxiety, PTSD, ADHD, and certain eating disorders (like bulimia). These examples regarding borderline personality disorder provide insight into the internal struggles of those who experience it. It's important to approach these topics with empathy and offer the necessary support to those facing this disorder  Histrionic Personality Disorder Histrionic Personality Disorder (HPD) is characterized by excessive emotionality and a strong need for attention. They command the role of “life of the party” Individuals with HPD feel uncomfortable if they are not the center of attention and may act dramatically or theatrically to draw focus, sometimes exaggerating or creating scenes. They often exhibit inappropriately flirtatious or seductive/provocative behavior in various settings, express shallow and rapidly changing emotions, and rely on their appearance to garner attention. They are overly concerned with impressing others by their appearance and expend an excessive amount of time, energy, and money on clothes and grooming. They may “fish for compliments” regarding appearance and may be easily and excessively upset by a critical comment about how they look or by a photograph that they regard as unflattering. Behavior with a clinician can be seen as being flattering, bringing gifts, and providing dramatic descriptions of physical and psychological symptoms that are replaced by new symptoms each visit) They may embarrass friends and acquaintances by an excessive public display of emotions (e.g., embracing casual acquaintances with excessive ardor, sobbing uncontrollably on minor sentimental occasions, having temper tantrums). Their speech tends to be impressionistic and lacking in detail, and they may display exaggerated emotions that can appear superficial, which may lead others to accuse the individual of faking these feelings.  Histrionic Personality Disorder Those with HPD are highly suggestible, easily influenced by others or current trends, and tend to perceive relationships as more intimate than they are. (such as describing almost every acquaintance as “my dear, dear friend” or referring to physicians met only once or twice under professional circumstances by their first names) They may be overly trusting, especially of strong authority figures whom they see as magically solving their problems. They have a tendency to play hunches and to adopt convictions quickly. They often engage in seductive behavior, have sexual fantasies, but may struggle with psychosexual dysfunctions like anorgasmia. Relationships tend to be superficial due to their vanity, self-absorption, and fickleness. Are typically cooperative during interviews, eager to share detailed histories with dramatic gestures and colorful language. They may have impaired reality testing under stress and lack awareness of their true feelings and motivations. Cognitive examinations usually show normal results, but patients may struggle with tasks requiring perseverance or concentration. Increased risk for major depression, somatic symptom disorder, and conversion disorder (aka as functional neurologic symptom disorder). Symptoms decrease with age, but energy levels may decrease too. Sensation seekers, prone to legal troubles, substance abuse, and promiscuity. Complications: frequent suicidal gestures, unstable relationships, marital problems  Narcissist Personality Disorder Narcissistic Personality Disorder (NPD) is marked by grandiosity, an excessive need for admiration, and a lack of empathy. Individuals with NPD overestimate their abilities and accomplishments, expect constant praise, and may feel entitled to special treatment from others. They are often preoccupied with fantasies of success and associate only with people or institutions they see as high-status; they may pursue fame and wealth ambitiously. Their sense of entitlement and lack of empathy often leads to exploiting others, whom they may view merely as tools for self-enhancement. They might feign sympathy to serve their own needs, but struggle to show genuine empathy. Relationships are often superficial and serve to reinforce their self-esteem, so their relationships are often strained, and impairing including marital problems. Underneath, however, their self-esteem is fragile and vulnerable to even minor criticism. Fragile self esteem makes them susceptible to depression, especially in response to interpersonal conflicts, occupational challenges, rejection or loss. Fragile self-esteem leads to difficulties with aging and midlife crises. They react poorly to criticism, often becoming enraged or indifferent. People with NPD are typically envious and dismissive of others’ successes, displaying arrogant or disdainful behaviors. Chronic and challenging to treat; symptoms diminish after 40. Narcissistic Personality Disorder  Cluster C - Fearful, Avoidant, Anxious Their symptoms stem from internal conflicts arising from dissatisfactory interpersonal relationships, leading to feelings of unworthiness, lack of value, judgment, and pressure. These struggles alter their functioning processes as a way to alleviate anxiety. Avoidant personality disorder is associated with anxiety disorders like social anxiety disorder, While obsessive-compulsive personality disorder (OCPD) is linked to obsessive-compulsive disorder (OCD).  Avoidant Personality Disorder Avoidant Personality Disorder (AvPD) is characterized by intense social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Begins in childhood with shyness and fear; severe impairment in social and occupational areas. Individuals with AvPD avoid interpersonal or work-related activities for fear of criticism, rejection, or disapproval. (hypersensitivity to rejection) They are highly reluctant to form new relationships unless assured of unconditional acceptance and may struggle with intimacy, often withholding personal feelings to avoid shame or ridicule. Individuals desire companionship but justify their avoidance of relationships due to a fear of rejection leading to a lack of close friendships or confidants. They are extremely sensitive to perceived criticism and may withdraw from social interactions due to low self-esteem and feelings of social ineptitude. Hypervigilance about rejection makes them hesitant to speak up or make requests, and they may misinterpret others' comments as derogatory. Refusal of requests leads to withdrawal and hurt feelings. They often express uncertainty, lack self-confidence, and may speak in a self- effacing manner. These individuals often avoid taking personal risks or trying new activities to prevent potential embarrassment, resulting in a restricted lifestyle. In work settings, they may choose sidelines roles and struggle to advance or assert authority. Avoidant Personality Disorder During clinical interviews, they display anxiety about interacting with the interviewer, and their demeanor may fluctuate based on perceived acceptance. We often describe this group as having an inferiority complex. Elevated risk for mood and anxiety disorders, especially social anxiety disorder. Can function in a protected environment but prone to depression, anxiety, and anger if the support system fails. Common complications: phobic avoidance. Uncritical acceptance: Not willing to criticize someone or something or to judge whether someone or something is right or wrong  Dependent Personality Disorder Dependent Personality Disorder (DPD) is marked by an excessive need to be cared for, leading to submissive, clinging behavior and a fear of separation. Individuals with DPD have difficulty making decisions without constant advice and reassurance (e.g., on routine matters) and often let others take responsibility for major life areas. They avoid taking on responsibilities and feel anxious about assuming leadership roles, preferring to be submissive. impaired occupational functioning due to dependence. When alone, they find it challenging to stay focused on tasks but may excel when performing tasks for others. Subordinate their own needs to those of others, get others to assume responsibility for significant areas of their lives, lack self-confidence, and may experience intense discomfort when alone for more than a brief period. They avoid expressing disagreement to maintain relationships, fear abandonment, and lack self-confidence, making it difficult to initiate tasks independently. To secure care, they may go to extreme lengths, including tolerating unreasonable demands or abuse. People with DPD seek out relationships where they can depend on others, leading to distorted dynamics marked by attachment needs. When a close relationship ends, they urgently seek a new one to avoid feeling helpless. and major depressive disorder if dependent figure is lost. Persistent, unrealistic fears of being unable to care for themselves alone are common. Traits of pessimism, self-doubt, passivity, and fear of expressing emotions like aggression or sexuality are typical in individuals with DPD. During interviews, individuals with DPD often present as compliant, welcoming specific questions and seeking guidance, reflecting their dependency on others for decision-making and support. Obsessive-Compulsive Personality Disorder (OCPD) Obsessive-Compulsive Personality Disorder (OCPD) is marked by a fixation on order, perfectionism, and control, compromising flexibility and efficiency. Individuals with OCPD are preoccupied with rules, lists, and details to the point that they lose sight of overall goals. Their perfectionism delays task completion, and they often miss deadlines due to repetitive checking and revisions. They prioritize work over leisure, approach hobbies as serious tasks, and may be excessively conscientious about morality and ethics, adhering rigidly to rules and regulations. They struggle to discard worthless items, dislike delegating tasks, are frugal to a fault, and exhibit rigidity and stubbornness, rejecting any approach differing from their own. They are rigid, lack flexibility, and are highly intolerant of imperfections or rule infractions. Persons with obsessive-compulsive personality disorder typically are emotionally constricted, orderly, perseverative, stubborn, and indecisive. People with OCPD are focused on achieving perfection and may engage in prolonged, routine work that doesn't require adaptation to change. Their interpersonal skills are limited, appearing formal, severe, and lacking in humor. Individuals with OCPD often struggle with indecision and ruminate excessively before making decisions due to their fear of making mistakes. Obsessive-Compulsive Personality Disorder (OCPD) While they may maintain stable marriages and occupational adequacy, they typically have few close friendships. Any disruption to their perceived stability or routine can cause significant anxiety, which they may attempt to manage through rigid rituals. During interviews, individuals with OCPD may exhibit a stiff, formal, and rigid demeanor. Their affect is serious, and they may appear anxious about losing control of the situation. Their responses tend to be detailed and may employ defense mechanisms like rationalization, isolation, intellectualization, reaction formation, and undoing. Higher risk for major depression and anxiety disorders. Co-occurrence with obsessive-compulsive disorder is uncertain. Variable course; occupational and social difficulties. Complications include distress in new situations and difficulties with flexibility and compromise. Personality Change due to a General Medical Condition Personality change due to a medical condition is notable, with the ICD-10 outlining categories like personality and behavioral disorders stemming from brain disease, damage, or dysfunction. This can lead to marked shifts in personality traits and emotional control, often linked to specific brain areas like the frontal lobes or conditions such as temporal lobe epilepsy. Key features include emotional lability, impulsivity, apathy, and behavioral changes like aggression or inappropriate social interactions. While some cases may be reversible, others may require ongoing care and supervision to manage conflicts and maintain stability. Treat underlying medical conditions; pharmacotherapy for specific symptoms like depression, irritability, aggression, or impulsivity; counseling for patients and families. Treatment - Psychotherapy Individuals with personality disorders typically do not perceive themselves as needing treatment and often only seek help when external pressures arise, such as relationship or career issues, or when other disorders complicate their situation. Treatment for personality disorders usually involves a combination of psychotherapy and pharmacotherapy: Psychotherapy: This is the primary treatment for personality disorders. It aims to promote and enhance the individual's psychosocial functioning, and adaptive personality traits and improve adaptive coping mechanisms. However, psychotherapy can be challenging initially in some patients due to unstable emotions and risky behaviors. As a result, pharmacotherapy is used in those patients initially to stabilize mood and behavior, making psychotherapy more effective. (e.g. patient with acute psychosis crisis, or acute manic crisis)  Treatment - Pharmacotherapy Medications are used to target specific symptoms of personality disorders. The goals include reducing subjective distress, controlling risky or self-destructive behaviors, and addressing interpersonal Antidepressants: conflicts. Mood stabilizers: Helpful for managing Used to manage depression, anxiety, By addressing these symptoms, pharmacotherapy helps mood swings and and obsessive- prepare individuals for psychotherapeutic interventions. impulsivity. compulsive The choice of medications depends on the target symptoms symptoms. and may include: Antipsychotics: Anti-anxiety Sometimes used to medications: Used address psychotic- for managing anxiety like symptoms or and agitation. severe agitation.  Prognosis Personality disorders are enduring conditions that can last for decades, impacting the success of treating co-occurring psychiatric disorders. They often lead to personal struggles, and higher morbidity rates, and can affect work, relationships, and education. People with personality disorders may also face challenges like substance dependence, unemployment, reliance on community services, and involvement with the criminal justice system.  References American Psychiatric Association. (2022). Personality Disorders. In Diagnostic and statistical manual of mental disorders (5th ed., Text Revision, pp. 734-778). American Psychiatric Association. Kaplan, B. J., & Sadock, V. A. (2022). Personality disorders. In Kaplan & Sadock's Comprehensive Textbook of Psychiatry (12th ed., pp. 1645-1694). Wolters Kluwer.