Personality Disorder Explained

Personality Trait

Enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts.

Personality Disorder

Enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture and is manifested in at least two of the areas

1. The pattern is manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning, or impulse control
2. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations
3. Leads to significant distress or impairment in social, occupational, or other important areas of functioning
4. The pattern is stable and of long duration, and its onset can be traced back to adolescence or early adulthood
5. The pattern is not better accounted for as a manifestation or consequence of another mental disorder
6. The pattern is not due to the direct physiologic effects of a substance or a general medical condition

Dimensions of Personality

Hippocrates – “Four humors”

1. Blood – Emotional lability
2. Black bile – Depression
3. Yellow bile – Anger
4. Phlegm – Slow, stolid, cold

Carl Jung – Psychological Types (1921)

1. Introvert- Extravert
2. Thinking- Feeling
3. Sensing- Intuiting
4. Judging- Perceiving

Assessment Instruments

• Self-report inventories
  • Minnesota Multiphasic Personality Inventory (MMPI, 1937), CPI
• Structured clinical interview for diagnosis (SCID) – Based on diagnostic criteria
• Clinical interview

Projective tests – Not diagnostic, but show patterns of thought, dynamics, defenses, disorders of thought, etc.

1. Rorschach (ink-blot)
2. Thematic Apperception Test (TAT) – (tell stories about evocative pictures)
3. Sentence-Completion Test (SCT) – (“I like…” “Sometimes I wish…”)
4. Draw-A-Person (DAP)

Prevalence

1. OCPD 2%
2. Paranoid 2%
3. Antisocial 1-4%
4. Schizoid 1%?
5. Schizotypal 1%
6. Avoidant 1-2%
7. Histrionic 2%
8. Borderline 2-3%
9. Dependent 5%
10. Narcissistic .5-1%

Etiology

Genetic and biologic factors

Concordance rates of personality traits for monozygotic twins are higher than for dizygotic twins, even if they are raised apart

Genetic and Biologic Factors:

Larry Siever

• Cognitive disorganization (includes “interpersonal detachment”) – Cluster A
• Impulsivity – Cluster B
  • Decreased 5-HT and 5-HIAA (5-HT metabolite)
• Affective instability – Cluster B
  • Hyperresponsivity of noradrenergic system
• Anxiety/Inhibition – Cluster C
  • High autonomic arousal from infancy

Robert Cloninger

• Novelty seeking
• Harm avoidance
• Reward dependence

Environmental factors

• Parenting and family style
• Psychosocial milieu

Psychodynamic factors

• Internal drives and defenses
• Developmental tasks and stages

Three Clusters

1. Cluster A (odd, eccentric, mad)
   • Paranoid
   • Schizoid
   • Schizotypal

1. Cluster B (dramatic, emotional, bad, Erratic)

• Antisocial
• Borderline
• Histrionic
• Narcissistic

1. Cluster C (anxious-fearful, sad)

• Avoidant
• Dependent
• Obsessive-compulsive

Paranoid Personality Disorder

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• A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent.
  • Suspects others are exploiting or deceiving him
  • Preoccupied with unjustified doubts about loyalty
  • Is reluctant to confide in others because he believes they will use the information against him
  • Reads hidden demeaning meanings into benign remarks
  • Perceives attacks on his character
  • Recurrent suspicions regarding fidelity of spouse or sexual partner
• Prevalence: 2% of the population.
• Sex ratio: F:M=3:1
• Comorbidity: Brief reactive psychosis, delusional disorder, anxiety, substance abuse, depression, schizophrenia
• Family: Delusional disorder, schizophrenia, Cluster A disorders

Schizoid Personality Disorder

• Pervasive pattern of detachment from social relationships and restricted expression of emotion with 4 or more the following:
  • Neither desires nor enjoys close relationships
  • Almost always chooses solitary activities
  • Little if any interest in sexual experiences with another person
  • Takes pleasure in few in any activities
  • Lacks close friends other than first-degree relatives
  • Appears indifferent to the praise or criticism of others
  • Shows emotional coldness or flattened affect
• Sex ratio: M>F
• Comorbidity: Delusional disorder, schizophrenia
• Family: Schizophrenia, Cluster A disorders, esp. schizotypal personality disorder

Schizotypal Personality Disorder

• A pervasive pattern of social and interpersonal deficits with reduced capacity for close relationships as well as cognitive or perceptual distortions and eccentricities of behavior with 5 or more of the following:
  • Ideas of reference
  • Odd beliefs or magical thinking
  • Unusual perceptual experiences including bodily illusions
  • Odd thinking and speech
  • Suspiciousness or paranoid ideation
  • Inappropriate or constricted affect
  • Behavior or appearance that is odd or eccentric
  • Lack of close friends other than first-degree relatives
  • Excessive social anxiety that does not diminish with familiarity
• Sex ratio: M>F
• Comorbidity: Depression, anxiety, brief reactive psychosis, delusional disorder, schizophrenia
• Family: Schizophrenia, Cluster A disorders.

Antisocial Personality Disorder

• A pervasive pattern of disregard for and violation of the rights of others occurring since the age of 15 years as indicated by 3 or more of the following:
  • Failure to conform to social norms to lawful behaviors
  • Deceitfulness and conning others for personal profit or pleasure
  • Impulsivity or failure to plan ahead
  • Irritability or aggressiveness as indicated by repeated fights or assaults
  • Reckless disregard for safety of self or others
  • Consistent irresponsibility
  • Lack of remorse
  • There is evidence of Conduct Disorder with onset before age 15
• Sex ratio: M: F=3:1
• Comorbidity: Substance abuse, attention deficit disorder, depression, anxiety
• Family: Somatization disorder, substance abuse, Cluster B disorders, esp. antisocial personality disorder
• Associations
  • Violence
  • Criminal behavior
  • Suicide

Borderline Personality Disorder

• Pervasive pattern of instability of interpersonal relationships, self-image and affects and marked impulsivity as indicated by 5 or more of the following:
  • Frantic efforts to avoid abandonment
  • Unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
  • Identity disturbance
  • Impulsivity in at least two areas that are potentially self-damaging
  • Recurrent suicidal behaviors, gestures or threats or self-mutilating behaviors
  • Affective instability due to a marked reactivity of mood
  • Chronic feelings of emptiness
  • Inappropriate anger
  • Transient, stress-related paranoia
• Sex ratio: F:M=3:1
• Comorbidity: Depression, substance abuse, eating disorders, brief reactive psychosis
• Family: Mood disorders, substance abuse, Cluster B disorders, esp. antisocial personality disorder
• Associations
  • Suicide and self-mutilation
  • Splitting – seeing the world as all good or all bad
  • Psychosis
  • Childhood trauma (especially sexual)
  • Dissociation- depersonalization, derealization, amnestic episodes

Histrionic Personality Disorder

• Pervasive pattern of excessive emotionality and attention seeking indicated by >5 of the following:
  • Uncomfortable in situations in which he is not the center of attention
  • Interaction with others often characterized by inappropriate sexually seductive behavior
  • Displays rapidly shifting and shallow expression of emotion
  • Consistently uses physical appearance to draw attention to self
  • Has a style of speech that is excessively impressionistic and lacking in detail
  • Shows self-dramatization and exaggerated emotion
  • Is suggestible
  • Considers relationships to be more intimate than they are
• Sex ratio: F>M
• Comorbidity: Somatization and conversion disorders, depression, anxiety
• Family: Cluster B disorders

Narcissistic Personality Disorder

• A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, lack of empathy as indicated by >5 of the following:
  • Grandiose sense of self-importance
  • preoccupied with fantasies of unlimited success, power, brilliance or beauty
  • Believes he is special and can only be understood or should associate with other special or high-status people
  • Requires excessive admiration
  • Has a sense of entitlement
  • Is interpersonally exploitive
  • Lacks empathy
  • Is often envious of others and believes others are envious of him
  • Shows arrogant, haughty behaviors or attitudes
• Sex ratio: 50-75% male
• Comorbidity: Mood disorders, anorexia, substance abuse
• Family: Cluster B disorders

Avoidant Personality Disorder

• A pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation as indicated by >4 of the following:
  • Avoids social occupations that involve significant interpersonal contact
  • Is unwilling to get involved with people unless certain of being liked
  • Is preoccupied with being criticized in social situations
  • Shows restraint in intimate relationships because of fear of being shamed or ridiculed
  • Inhibited in new interpersonal situations because of feeling inadequate
  • Views self as socially inept and unappealing
  • Is unusually reluctant to take personal risks or engage in any new activities because they may prove embarrassing
• Sex ratio: M=F
• Comorbidity: Social phobia, depression, anxiety
• Family: Cluster C disorders

Dependent Personality Disorder

• A pervasive and excessive need to be taken care of that leads to submissive and clinging behaviors and fears of separation as indicated by >5 of the following:
  • Has difficulty making everyday decisions without an excessive amount of reassurance
  • Needs others to assume responsibility for most major areas of his life
  • Has difficulty expressing disagreement with others because of fear of loss of approval
  • Difficulty initiating projects on his own because of lack of self-confidence
  • Goes to excessive lengths to obtain nurturance and support from others
  • Feels uncomfortable or helpless when alone
  • Urgently seeks another relationship as a source of care and support when a relationship ends
  • Is unrealistically preoccupied with fears of being left to take care of himself
• Sex ratio: F>M
• Comorbidity: Mood and anxiety disorders, adjustment disorders
• Family: Cluster C disorders

OCPD/ Anankastic Personality Disorder

• A pervasive pattern of preoccupation with orderliness, perfectionism and mental and interpersonal control at the expense of flexibility, openness as indicated by >4 of the following:
  • Preoccupied with details, rules, lists, order or schedules to the extent that the major point of the activity is lost
  • Shows rigidity and stubbornness
  • Perfectionism that interferes with task completion
  • Excessively devoted to work and productivity to the exclusion of leisure activity and friends
  • Over-conscientious and inflexible about matters of morals or ethics
  • Is unable to discard worn or worthless objects even those without sentimental value
  • Reluctant to delegate tasks
  • Adopts miserly spending style toward self and others
• Sex ratio: M:F=2:1
• Comorbidity: Slight increase in mood and anxiety disorders
• Family: Obsessive-compulsive personality disorder

Challenge of Working With Personality Disorders

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1. Patients typically come for therapy with presenting problems other than personality problems
2. They require more work within the session
3. Longer duration of treatment
4. Greater strain on the therapist’s skills and patience
5. Greater difficulty in treatment compliance

Treatment

1. Can reduce symptomatology, improve social and interpersonal functioning, reduce the frequency of maladaptive behaviors and decrease hospitalizations.
2. Always screen for comorbid psychiatric diagnosis
3. If the personality disorder is ego-syntonic (eg. Antisocial and Narcissistic) it will be hard to engage the patient in treatment

Medications

1. Increasing serotonin levels may reduce depression, impulsiveness, rumination and may enhance a sense of well-being
2. Low-dose neuroleptics and mood stabilizers may be effective in modulating affective stability

Therapy

1. For BPD DBT, Schema-focused therapy, transference-focused therapy, and Mentalization-based treatment have all been found to be effective.
2. Therapy for other disorders limited to a small number of open-labeled trials and case studies. These findings have been positive.

Screening for comorbid disorders

1. Antisocial PD: Alcohol dependence and depressive disorders
2. BPD: alcohol and drug dependence, mood disorders, anxiety disorders inc PTSD
3. Histrionic PD: alcohol dependence, somatization disorder
4. Avoidant PD: social phobia
5. Any PD puts pt at higher risk than the general population for drug dependency.