PERSONALITY DISORDERS.ppt

PERSONALITY DISORDERS

Windsor University School of
Medicine

Psychiatry Rotation
Consultant Psychiatrist – Dr. Sharon
Halliday

Presentation by:
OLADAPO SAMSON OLUWABUKOLA
TH

Definition of terms
 Personality Disorders can be defined broadly as
inflexible and maladaptive patterns of behaviour.
 They are pervasive, persistent, inflexible, maladaptive
patterns of behaviour that deviate from expected cultural
norms. They cause significant distress or functional
impairment. Diagnosis is clinical. Treatment is with
psychotherapy and sometimes drug therapy.
 Personality disorder, as defined in the Diagnostic and
Statistical Manual of the American Psychiatric
Association, Fourth Edition, Text Revision (DSM-IV-
TR), is an enduring pattern of inner experience and
behavior that differs markedly from the expectations of
the individual's culture, is pervasive and inflexible, has an
onset in adolescence or early adulthood, is stable over
time, and leads to distress or impairment.
 Personality disorders are a long-standing and
maladaptive pattern of perceiving and responding to
other people and to stressful circumstances.

An Overview of Human
Personality!
 Personality is the combination of thoughts, emotions and
behaviors that makes you unique. It's the way you view,
understand and relate to the outside world, as well as how
you see yourself. Personality forms during childhood,
shaped through an interaction of two factors:
 Inherited tendencies, or your genes. These are aspects of
your personality passed on to you by your parents, such as
shyness or having a happy outlook. This is sometimes called
your temperament. It's the "nature" part of the nature vs.
nurture debate.
 Environment, or your life situations. This is the
surroundings you grew up in, events that occurred, and
relationships with family members and others. It includes such
things as the type of parenting you had, whether loving or
abusive. This is the "nurture" part of the nature vs. nurture

An Overview of Human
Personality!

PERSONALITY
DEVELOPMENT &
THEORIES

Personality Development &
Theories
 Personality development has been a major topic of interest
for some of the most prominent thinkers in psychology and
also of great concern for psychiatrist in that understanding
how and why we become what we are is one of the basic
core principle and tools used in psychiatry for diagnosis.
Our personalities make us unique.
 The following theories focus on various aspects of
personality development, including cognitive, social and
moral development.
 Piaget’s Stages of Cognitive Development
 Freud’s Stages of Psychosexual Development
 Freud’s Structural Model of Personality
 Erikson’s Stages of Psychosocial Development
 Kohlberg’s Stages of Moral Development

Piaget’s Stages of Cognitive
Development
 While many aspects of his theory have not stood the test of time, the
central idea remains important today: children think differently than
adults. Albert Einstein called Piaget's discovery "so simple only a
genius could have thought of it."
 Piaget's stage theory describes the cognitive development of children.
Cognitive development involves changes in cognitive process and
abilities. In Piaget's view, early cognitive development involves processes
based upon actions and later progresses into changes in mental
operations.
 Key Concepts
 Schemas - A schema describes both the mental and physical actions
involved in understanding and knowing. Schemas are categories of
knowledge that help us to interpret and understand the world.
 In Piaget's view, a schema includes both a category of knowledge
and the process of obtaining that knowledge. As experiences
happen, this new information is used to modify, add to, or change
previously existing schemas.
 For example, a child may have a schema about a type of
animal, such as a dog. If the child's sole experience has been with
small dogs, a child might believe that all dogs are small, furry, and
have four legs. Suppose then that the child encounters a very large
dog. The child will take in this new information, modifying the
previously existing schema to include this new information.

Piaget’s Stages of Cognitive
Development
 Assimilation - The process of taking in new information into our
previously existing schema's is known as assimilation. The process
is somewhat subjective, because we tend to modify experience or
information somewhat to fit in with our preexisting beliefs. In the
example above, seeing a dog and labeling it "dog" is an example of
assimilating the animal into the child's dog schema.
 Accommodation - Another part of adaptation involves changing or
altering our existing schemas in light of new information, a process
known as accommodation. Accommodation involves altering
existing schemas, or ideas, as a result of new information or new
experiences. New schemas may also be developed during this
process.
 Equilibration - Piaget believed that all children try to strike a
balance between assimilation and accommodation, which is
achieved through a mechanism Piaget called equilibration. As
children progress through the stages of cognitive
development, it is important to maintain a balance between
applying previous knowledge (assimilation) and changing
behavior to account for new knowledge (accommodation).
Equilibration helps explain how children are able to move from

Freud’s Stages of Psychosexual
Development
 Freud suggested that personality develops in stages that
are related to specific erogenous zones. Failure to
successfully complete these stages, he suggested, would
lead to personality problems in adulthood.
 Freud's theory of psychosexual development is one of the
best known, but also one of the most controversial. Freud
believed that personality develops through a series of
childhood stages during which the pleasure-seeking
energies of the id become focused on certain erogenous
areas. This psychosexual energy, or libido, was described
as the driving force behind behavior.
 If these psychosexual stages are completed successfully,
the result is a healthy personality. If certain issues are not
resolved at the appropriate stage, fixation can occur. A
fixation is a persistent focus on an earlier psychosexual
stage. Until this conflict is resolved, the individual will
remain "stuck" in this stage. For example, a person who is
fixated at the oral stage may be over-dependent on others
and may seek oral stimulation through smoking, drinking,

Development
STAG EROGENOU AGE REMARKS
E S ZONE RANG
E
Oral Mouth Birth – •Rooting and sucking reflex is especially important
•The primary conflict at this stage is the weaning process--
Stage 1 year the child must become less dependent upon caretakers. If
fixation occurs at this stage, Freud believed the individual
would have issues with dependency or aggression. Oral
fixation can result in problems with drinking, eating,
smoking or nail biting.
Anal Bowel and 1–3 •Primary focus of the libido was on controlling bladder and
bowel movements.
Stage Bladder years •The major conflict at this stage is toilet training--the child
control has to learn to control his or her bodily needs. Developing
this control leads to a sense of accomplishment and
independence.
•Freud believed that positive experiences during this stage
served as the basis for people to become competent,
productive and creative adults.
•If parents take an approach that is too lenient, Freud
suggested that an anal-expulsive personality could develop
in which the individual has a messy, wasteful or destructive
personality.
•If parents are too strict or begin toilet training too early,
Freud believed that an anal-retentive personality develops

Development
STAG EROGENOU AGE REMARKS
E S ZONE RANG
E
Phallic Genitals 3–6 •At this age, children also begin to discover the
differences between males and females.
Stage years
•Eventually, the child begins to identify with the same-sex
parent as a means of vicariously possessing the other
parent.
Latent Sexual 6 to •The libido interests are suppressed. The development of
stage feelings are puberty the ego and superego contribute to this period of calm.
•The stage begins around the time that children enter into
inactive school and become more concerned with peer
relationships, hobbies and other interests.
•The latent period is a time of exploration in which the
sexual energy is still present, but it is directed into other
areas such as intellectual pursuits and social interactions.
This stage is important in the development of social and
communication skills and self-confidence.
Genital Maturing Puberty •The individual develops a strong sexual interest in the
opposite sex.
Stage sexual to
•Where in earlier stages the focus was solely on individual
interest death needs, interest in the welfare of others grows during this
stage.
•If the other stages have been completed successfully,

Development
 Evaluating Freud’s Psychosexual Stage Theory
 The theory is focused almost entirely on male
development with little mention of female psychosexual
development.
 His theories are difficult to test scientifically. Concepts
such as the libido are impossible to measure, and
therefore cannot be tested. The research that has been
conducted tends to discredit Freud's theory.
 Future predictions are too vague. How can we know that
a current behavior was caused specifically by a
childhood experience? The length of time between the
cause and the effect is too long to assume that there is a
relationship between the two variables.
 Freud's theory is based upon case studies and not
empirical research. Also, Freud based his theory on the
recollections of his adult patients, not on actual

Freud’s Structural Model of
Personality
 According to Sigmund Freud's psychoanalytic theory of
personality, personality is composed of three elements. These three
elements of personality--known as the id, the ego and the superego –
work together to create complex human behaviors.
 The Id
 The id is the only component of personality that is present from birth.
This aspect of personality is entirely unconscious and includes of the
instinctive and primitive behaviors. According to Freud, the id is the
source of all psychic energy, making it the primary component of
personality.
 The id is driven by the pleasure principle, which strives for immediate
gratification of all desires, wants, and needs. If these needs are not
satisfied immediately, the result is a state anxiety or tension. For
example, an increase in hunger or thirst should produce an immediate
attempt to eat or drink. The id is very important early in life, because it
ensures that an infant's needs are met. If the infant is hungry or
uncomfortable, he or she will cry until the demands of the id are met.
 However, immediately satisfying these needs is not always realistic or
even possible. If we were ruled entirely by the pleasure principle, we
might find ourselves grabbing things we want out of other people's hands
to satisfy our own cravings. This sort of behavior would be both
disruptive and socially unacceptable. According to Freud, the id tries to
resolve the tension created by the pleasure principle through the primary

Personality
 The Ego
 The ego is the component of personality that is responsible for dealing with
reality. According to Freud, the ego develops from the id and ensures that the
impulses of the id can be expressed in a manner acceptable in the real world.
The ego functions in both the conscious, preconscious, and unconscious
mind.
 The ego operates based on the reality principle, which strives to satisfy the
id's desires in realistic and socially appropriate ways. The reality principle
weighs the costs and benefits of an action before deciding to act upon or
abandon impulses. In many cases, the id's impulses can be satisfied through
a process of delayed gratification--the ego will eventually allow the
behavior, but only in the appropriate time and place.
 The ego also discharges tension created by unmet impulses through the
secondary process, in which the ego tries to find an object in the real world
that matches the mental image created by the id's primary process.
 The Superego
 The last component of personality to develop is the superego. The superego
is the aspect of personality that holds all of our internalized moral standards
and ideals that we acquire from both parents and society--our sense of right
and wrong. The superego provides guidelines for making judgments.
 According to Freud, the superego begins to emerge at around age five.

Personality
 There are two parts of the superego:
 The ego ideal includes the rules and standards for good behaviors. These
behaviors include those which are approved of by parental and other
authority figures. Obeying these rules leads to feelings of pride, value and
accomplishment.
 The conscience includes information about things that are viewed as bad
by parents and society. These behaviors are often forbidden and lead to
bad consequences, punishments or feelings of guilt and remorse.
 The superego acts to perfect and civilize our behavior. It works to
suppress all unacceptable urges of the id and struggles to make the ego
act upon idealistic standards rather that upon realistic principles. The
superego is present in the conscious, preconscious and unconscious.
 The Interaction of the Id, Ego and Superego
 With so many competing forces, it is easy to see how conflict might arise
between the id, ego and superego. Freud used the term ego strength to refer
to the ego's ability to function despite these dueling forces. A person with
good ego strength is able to effectively manage these pressures, while those
with too much or too little ego strength can become too unyielding or too
disrupting.
 According to Freud, the key to a healthy personality is a balance
between the id, the ego, and the superego.

Erikson’s Stages of Psychosocial
Development
 Erikson's theory describes the impact of social experience across
the whole lifespan.
 One of the main elements of Erikson's psychosocial stage theory is
the development of ego identity. Ego identity is the conscious
sense of self that we develop through social interaction.
 According to Erikson, our ego identity is constantly changing due to
new experiences and information we acquire in our daily
interactions with others. In addition to ego identity, Erikson also
believed that a sense of competence motivates behaviors and
actions. Each stage in Erikson's theory is concerned with becoming
competent in an area of life. If the stage is handled well, the
person will feel a sense of mastery, which is sometimes
referred to as ego strength or ego quality. If the stage is
managed poorly, the person will emerge with a sense of
inadequacy.
 In each stage, Erikson believed people experience a conflict that
serves as a turning point in development. In Erikson's view, these
conflicts are centered on either developing a psychological quality
or failing to develop that quality. During these times, the potential
for personal growth is high, but so is the potential for failure.

Development
 Psychosocial Stage 1 - Trust vs. Mistrust
 The first stage of Erikson's theory of psychosocial development occurs
between birth and one year of age and is the most fundamental stage in
life.2
 Because an infant is utterly dependent, the development of trust is based
on the dependability and quality of the child's caregivers.
 If a child successfully develops trust, he or she will feel safe and secure in
the world. Caregivers who are inconsistent, emotionally unavailable, or
rejecting contribute to feelings of mistrust in the children they care for.
Failure to develop trust will result in fear and a belief that the world is
inconsistent and unpredictable.
 Psychosocial Stage 2 - Autonomy vs. Shame and Doubt
 The second stage of Erikson's theory of psychosocial development takes
place during early childhood and is focused on children developing a
greater sense of personal control.
 Like Freud, Erikson believed that toilet training was a vital part of this
process. However, Erikson's reasoning was quite different then that of
Freud's. Erikson believe that learning to control one's bodily functions leads
to a feeling of control and a sense of independence.
 Other important events include gaining more control over food choices, toy
preferences, and clothing selection.
 Children who successfully complete this stage feel secure and confident,
while those who do not are left with a sense of inadequacy and self-doubt.

Development
 Psychosocial Stage 3 - Initiative vs. Guilt
 During the preschool years, children begin to assert their power and control
over the world through directing play and other social interactions.
 Children who are successful at this stage feel capable and able to lead others.
Those who fail to acquire these skills are left with a sense of guilt, self-doubt,
and lack of initiative.3
 Psychosocial Stage 4 - Industry vs. Inferiority
 This stage covers the early school years from approximately age 5 to 11.
 Through social interactions, children begin to develop a sense of pride in their
accomplishments and abilities.
 Children who are encouraged and commended by parents and teachers
develop a feeling of competence and belief in their skills. Those who receive
little or no encouragement from parents, teachers, or peers will doubt their
abilities to be successful.
 Psychosocial Stage 5 - Identity vs. Confusion
 During adolescence, children explore their independence and develop a sense
of self.
 Those who receive proper encouragement and reinforcement through personal
exploration will emerge from this stage with a strong sense of self and a feeling
of independence and control. Those who remain unsure of their beliefs and
desires will feel insecure and confused about themselves and the future.

Development
 Psychosocial Stage 6 - Intimacy vs. Isolation
 This stage covers the period of early adulthood when people are exploring
personal relationships.
 Erikson believed it was vital that people develop close, committed relationships
with other people. Those who are successful at this step will form relationships
that are committed and secure.
 Remember that each step builds on skills learned in previous steps. Erikson
believed that a strong sense of personal identity was important for developing
intimate relationships. Studies have demonstrated that those with a poor sense
of self tend to have less committed relationships and are more likely to suffer
emotional isolation, loneliness, and depression.
 Psychosocial Stage 7 - Generativity vs. Stagnation
 During adulthood, we continue to build our lives, focusing on our career and
family.
 Those who are successful during this phase will feel that they are contributing
to the world by being active in their home and community. Those who fail to
attain this skill will feel unproductive and uninvolved in the world.
 Psychosocial Stage 8 - Integrity vs. Despair
 This phase occurs during old age and is focused on reflecting back on life.
 Those who are unsuccessful during this stage will feel that their life has been
wasted and will experience many regrets. The individual will be left with feelings
of bitterness and despair.
 Those who feel proud of their accomplishments will feel a sense of integrity.

Kohlberg’s Stages of Moral
Development
 Lawrence Kohlberg who modified and expanded upon Jean
Piaget's work to form a theory that explained the development of
moral reasoning.
 Piaget described a two-stage process of moral development, while
Kohlberg's theory of moral development outlined six stages within
three different levels. Kohlberg extended Piaget's
theory, proposing that moral development is a continual process
that occurs throughout the lifespan.
 Level 1. Preconventional Morality
 Stage 1 - Obedience and Punishment – The earliest stage of
moral development is especially common in young children, but
adults are also capable of expressing this type of reasoning. At
this stage, children see rules as fixed and absolute. Obeying the
rules is important because it is a means to avoid punishment.
 Stage 2 - Individualism and Exchange – At this stage of moral
development, children account for individual points of view and
judge actions based on how they serve individual needs. In the
Heinz dilemma, children argued that the best course of action
was the choice that best-served Heinz’s needs. Reciprocity is
possible at this point in moral development, but only if it serves

Development
 Level 2. Conventional Morality
 Stage 3 - Interpersonal Relationships – Often referred to as
the "good boy-good girl" orientation, this stage of moral
development is focused on living up to social expectations and
roles. There is an emphasis on conformity, being "nice," and
consideration of how choices influence relationships.
 Stage 4 - Maintaining Social Order – At this stage of moral
development, people begin to consider society as a whole when
making judgments. The focus is on maintaining law and order by
following the rules, doing one’s duty and respecting authority.
 Level 3. Postconventional Morality
 Stage 5 - Social Contract and Individual Rights – At this
stage, people begin to account for the differing values, opinions
and beliefs of other people. Rules of law are important for
maintaining a society, but members of the society should agree
upon these standards.
 Stage 6 - Universal Principles – Kolhberg’s final level of moral
reasoning is based upon universal ethical principles and
abstract reasoning. At this stage, people follow these
internalized principles of justice, even if they conflict with laws

Development
 Criticisms of Kohlberg's Theory of Moral Development:
 Does moral reasoning necessarily lead to moral behavior?
Kohlberg's theory is concerned with moral thinking, but
there is a big difference between knowing what we ought
to do versus our actual actions.
 Is justice the only aspect of moral reasoning we should
consider? Critics have pointed out that Kohlberg's theory of
moral development overemphasizes the concept as justice
when making moral choices. Factors such as
compassion, caring and other interpersonal feelings may
play an important part in moral reasoning.
 Does Kohlberg's theory overemphasize Western
philosophy? Individualistic cultures emphasize personal
rights while collectivist cultures stress the importance of
society and community. Eastern cultures may have

Overview of Clusters
 Basically, Personality Disorders, PDs, are things people do
that probably annoy everybody else but as far as we are
concern, we are okay and its everyone else who have the
problem. Thinking about this in the psychiatric terms, PDs
patients tend to be egodystonic, meaning they are okay
with themselves and happy with the way they are.
 CLUSTERS
 A- Odd eccentric type includes paranoid, schizoid and
schizotypal)
 B – Dramatic emotional type includes
borderline, narcissistic, histrionic and antisocial
 C - Anxious – Fearful type includes avoidance, obsessive-
compulsive and dependent.
 Not specified – Depressive, passive-aggressive, Sadistic and
Self-defeating.

Incidence
 Because the DSM-IV-TR criteria are so bound to North
American cultural definitions, epidemiologic data about
personality disorders in other countries are notoriously
unreliable, but nonetheless the incidence ranges between 5-
10% of the general population.
 Taking the United State as a case study, personality disorders
affect 10-15% of the adult US population. Individuals may have
more than one personality disorder. The following are
prevalences for specific personality disorders in the general
population:
 Paranoid personality disorder - 0.5-2.5%
 Schizotypal (Schizoid) personality disorder - 3%
 Antisocial personality disorder - 3% of men, 1% of women
 Borderline personality disorder - 2%
 Histrionic personality disorder - 2-3%
 Narcissistic personality disorder - Less than 1%
 Avoidant personality disorder - 0.5-1%
 Obsessive-compulsive personality disorder - 1%

Epidemiological Facts
 Race: No differences in prevalence across the races have been noted.
 Sex
 Cluster A: Schizoid personality disorder is slightly more common in
males than in females.
 Cluster B: Antisocial personality disorder is 3 times more prevalent in
men than in women. Borderline personality disorder is 3 times more
common in women than in men. Of patients with narcissistic
personality disorder, 50-75% are male.
 Cluster C: Obsessive-compulsive personality disorder is diagnosed
twice as often in men than in women.
 Age: Personality disorders generally should not be diagnosed in
children and adolescents because personality development is not
complete and symptomatic traits may not persist into adulthood.
Therefore, the rule of thumb is that personality diagnosis cannot
be made until the person is at least 18 years of age. Because the
criteria for diagnosis of personality disorders are closely related to
behaviors of young and middle adulthood, DSM-IV-TR diagnoses of
personality disorders are notoriously unreliable in the elderly population.
 Mortality/Morbidity: Risk of death is usually related to conditions or
behaviors resulting from the disorder, such as suicide, substance abuse,
or injuries from motor vehicle accidents and fighting.

Risk Factors
 Nobody, actually, knows what causes personality disorders – are
we born this way or do we learn to become this way; chances are
its going to be a little bit of both.
 Thus risk factors or more likely the predisposing factors to PDs
include:
 Innate temperamental difficulties
 Adverse environmental events
 Personality disorders in parents – something we learn from
patents and we watch them react to things and that’s how we
become as well.
 Low socioeconomic status
 Verbal, physical or sexual abuse during childhood
 Neglect during childhood
 An unstable or chaotic family life during childhood
 Being diagnosed with childhood conduct disorder
 Loss of parents through death or traumatic divorce during
childhood
Personality disorders often begin in childhood and last through
adulthood. There's reluctance to diagnose personality disorders
in a child, though, because the patterns of behavior and thinking

Etiology
 Etiology is not clearly known, but several studies and theories
concerning the etiology include:
 Personality disorders are thought to result from a bad
interface, so to speak, between a child's temperament and
character on one hand and his or her family environment on
the other.
 Personality disorders are thought to be caused by a
combination of genetic and environmental influences. You
may have a genetic vulnerability to developing a personality
disorder and your life situation may trigger the actual
development of a personality disorder.
 In the past, some believed that people with personality
disorders were just lazy or even evil. But new research has
begun to explore such potential causes as genetics, parenting
and peer influences:
 Genetic
 Psychological
 Social

Etiology – Genetic
 Genetics. Researchers are beginning to identify
some possible genetic factors behind personality
disorders. Some have been able to identify a
malfunctioning gene that may be a factor in
obsessive-compulsive disorder while others are
exploring genetic links to aggression, anxiety and
fear – traits that can play a role in personality
disorders.

Etiology – Psychological
 High reactivity. Sensitivity to light, noise, texture and
other stimuli may also play a role.
 Overly sensitive children, who have what
researchers call “high reactivity,” are more likely to
develop shy, timid or anxious personalities.
 However, high reactivity’s role is still far from clear-
cut. Twenty percent of infants are highly
reactive, but less than 10 percent go on to develop
social phobias.

Etiology – Social
 Verbal abuse. Even verbal abuse can have an
impact. In a study of 793 mothers and children,
researchers asked mothers if they had screamed at
their children, told them they didn’t love them or
threatened to send them away. Children who had
experienced such verbal abuse were three times as
likely as other children to have borderline, narcissistic,
obsessive-compulsive or paranoid personality
disorders in adulthood.
 Peers. Certain factors can help prevent children from
developing personality disorders.
 Even a single strong relationship with a relative,
teacher or friend can offset negative influences, say
psychologists.

Etiology – Social
 Childhood trauma. Findings from one of the largest
studies of personality disorders, the Collaborative
Longitudinal Personality Disorders Study, offer clues
about the role of childhood experiences.
 One study found a link between the number and
type of childhood traumas and the development of
personality disorders. People with borderline
personality disorder, for example, had especially
high rates of childhood sexual trauma and this also
justifies the prevalence of borderline personality
disorder among females.

Etiology - Social
 Other factors that have been cited as affecting
children's personality development are the mass
media and social or group hysteria, particularly after
the events of September 11, 2001. Cases of so-called
mass sociogenic illness have been identified, in which
a group of children began to vomit or have other
physical symptoms brought on in response to an
imaginary threat. In two such cases, the children were
reacting to the suggestion that toxic fumes were
spreading through their school. Some authors believe
that overly frequent or age-inappropriate discussions
of terrorist attacks or bioterrorism may make children
more susceptible to sociogenic illness as well as other

Pathogenesis
 Abnormalities may be seen in the frontal, temporal, and parietal lobes.
These abnormalities may be caused by perinatal
injury, encephalitis, trauma, or genetics. Personality disorders are also
seen with diminished monoamine oxidase (MAO) and serotonin levels.
Relationships of anatomy, receptors, and neurotransmitters to personality
disorders are purely speculative at this point.
 Frequently, a history of psychiatric disorders is present. Developmental
abnormalities secondary to abuse or incest may be present.
 The 5-factor model has been used to describe the different accepted types
of personality disorders. Most current research suggests that personality
disorders may be differentiated by their interactions among the 5
dimensions rather than differences on any single dimension.
 In general, patients with personality disorders have wide-ranging problems
in social relationships and mood regulation. These problems have usually
been present throughout adult life. These patients' patterns of
perception, thought, and response are fixed and inflexible, although their
behavior is often unpredictable. These patterns markedly deviate from
their specific culture's expectations.
 To meet the DSM-IV threshold for clinical diagnosis, the pattern must
result in clinically significant distress or impairment in
social, occupational, or other important areas of functioning.

Pathophysiology
 The origin of personality disorders is a matter of
considerable controversy. Traditional thinking holds
that these maladaptive patterns are the result of
dysfunctional early environments that prevent the
evolution of adaptive patterns of
perception, response, and defense. A body of data
points toward genetic and psychobiologic
contributions to the symptomology of these disorders;
however, the inconsistency of the data prevents
authorities from drawing definite conclusions.

Clinical Features
 General symptoms of a
personality disorder
 Frequent mood swings
 Stormy relationships
 Social isolation
 Angry outbursts
 Suspicion and mistrust of
others
 Difficulty making friends
 A need for instant
gratification
 Poor impulse control
 Alcohol or substance
abuse

Clinical features - Clusters
 The two major systems of classification, the ICD and DSM, have
deliberately merged their diagnoses to some extent, but there remain
differences. For example, ICD-10 does not include narcissistic
personality disorder as a distinct category, while DSM-IV does not
include enduring personality change after catastrophic experience or
after psychiatric illness. ICD-10 classifies the DSM-IV schizotypal
personality disorder as a form of schizophrenia rather than as a
personality disorder. DSM-IV places personality disorders on a
separate 'axis' to mental disorders, while the ICD does not use a
multiaxial system. There are accepted diagnostic issues and
controversies with regard to either section, in terms of distinguishing
personality disorders as a category from other types of mental disorder
or from general personality Bfunctioning, or distinguishing particular
CLUSTER A CLUSTER CLUSTER C NOT SPECIFIED
personality disorder categories from each other.
(ODD) (DRAMATIC) (ANXIOUS)
Paranoid Borderline Avoidant Depressive
Schizoid Narcissistic Dependent Passive-
Schizotypal Histrionic Obsessive- aggressive
Antisocial compulsive Sadistic
Self-defeating
Cyclothymic

CLUSTER A – Odd Eccentric Type
 Includes the paranoid, schizoid and
schizotypal personality disorders.
Affected individuals use the defense
mechanism of projection and fantasy and
may have a tendency toward psychotic
thinking.
 Projection involves attributing to
another person the thoughts or
feelings of one’s own that are
unacceptable
 Fantasy is the creation of an
imaginary life with which the patient
deals with loneliness. A fantasy can be
quite elaborate and extensive.
 Paranoia is a feeling of being persecuted
or treated unfairly by others. Paranoid
patients may feel that others are talking
about or making fun of them.
 Biologically, patients with cluster A
personality disorders may have a
vulnerability to cognitive disorganization
when stressed. These disorders do not
occur exclusively during the course of
schizophrenia, which is a mood disorder

Cluster A – Paranoid
 Individuals with this disorder display
pervasive distrust and suspiciousness.
Common beliefs include the following:
 Others are exploiting or deceiving the person.
 Friends and associates are untrustworthy.
 Information confided to others will be used
maliciously.
 There is hidden meaning in remarks or events
others perceive as benign.
 The spouse or partner is Personality
Major traits of the Paranoid unfaithful. Disorder, PPD, include:
•Expectations of being harmed or exploited without a sufficient bias
•Preoccupation with unjustified doubts
•Reluctance to confide in others
•Persistently bearing grudges
•Perceiving attacks on character or reputation not apparent to others.
•Never give up personal information out of fear
•Hallucinate that people are chasing them or attacking them which sometimes
leads to a violent reaction
•They cannot see that they are wrong with their thoughts
•Can be hostile and prone to arguments

Cluster A - Paranoid
 The same as most personality disorders, people
with PPD don’t realize they have a problem and
are not likely to seek professional help unless
other issues appear.
 The prevalence of paranoid personality disorder is
unknown. People tend to group themselves in
esoteric religions and pseudoscientific and
quasipolitical groups. Groups of paranoid
individuals who set themselves apart and see
others as “the enemy” tend to provoke negative
reactions from the outside, which reinforces their
paranoid views.
 Causes: A genetic contribution to paranoid traits
and a possible genetic link between this

Cluster A - Paranoid
 Summarily, Paranoid personality involves coldness and
distancing in relationships, with a need for control and a
tendency toward jealousy if attachments are formed.
Affected people are often secretive and untrusting. They
tend to be suspicious of changes and frequently find hostile
and malevolent motives behind other people’s acts.
Often, these hostile motives represent projections of their
own hostilities onto others. Their reactions sometimes
surprise or scare others. They then use the resulting anger
of or rejection by others (i.e., projective identification) to
justify their original feelings. Paranoid people tend to feel a
sense of righteous indignation and often take legal action
against others. These people may be highly efficient and
conscientious, although they usually need to work in relative
isolation. This disorder must be differentiated from
paranoid schizophrenia.

Cluster A - Schizoid
 This type of personality disorder is uncommon in clinical
settings. A person with this disorder is markedly detached
from others and has little desire for close relationships.
This person's life is marked by little pleasure in activities
and tends to be anhedonic. People with this disorder
appear indifferent to the praise or criticism of others and
often seem cold or aloof.
 It can be described as pervasive pattern of detachment
from social relationships and restriction of emotion in
interpersonal settings that begins by early adulthood.
 Characterized by the following major traits:
 Neither desiring nor enjoying close relationships; choosing
solitary activities
 Little interest in sex
 Indifference to praise or criticism
 Emotional frigidity

 Because patients with schizoid personality disorder rarely
seek treatment, the prevalence of this condition is
unknown. Schizoid personality disorder is present in a
variety of contexts.
 The diagnosis can be made when at least four of following
is present:
 No desire or enjoyment of close relationships, including being
part of a family
 Choice of solitary activities (almost always)
 Little, if any, interest in having sexual experiences with
another person
 Enjoyment of few, if any, activities
 Lack of close friends or confidants other than first-degree
relatives
 Apparent indifference to the praise or criticism of others
 Emotional coldness, detachment, or flattened affect

 Summarily, Schizoid personality is characterized by
introversion, social withdrawal, isolation, and
emotional coldness and distancing. Affected
individuals are often absorbed in their own thoughts
and feelings and fear closeness and intimacy with
other people. They are reticent, are given to
daydreaming, and prefer theoretical speculation to
practical action.

Cluster A – Schizotypal
 Several studies indicate that 3% of the population has this
disorder. The problems posed by treating patients with
schizotypal personality disorder and a medical or surgical
illness are similar to those encountered with schizoid
patients. Illness threatens their isolation.
 The central features of this disorder are pervasive
patterns of “strange” or “odd” thought, perception, and
behavior.
 These peculiarities are not so severe that they can be
termed schizophrenic, and there is no history of psychotic
episodes. A pervasive pattern of social and interpersonal
deficits marked by acute discomfort with, and reduced
capacity for, close relationships is indicative.
 People with this disorder exhibit marked eccentricities of
thought, perception, and behavior.
 Cognitive or perceptual distortions also occur.

 Schizotypal personality disorder is indicated by the
presence of at least five of the following:
 Ideas of reference (i.e., believing that public messages
are directed personally at them)
 Odd beliefs or magical thinking that influence behavior and
are inconsistent with sub-cultural norms (e.g., belief in
superstitions, clairvoyance, telepathy, or “sixth sense”, in
children and adolescents, bizarre fantasies or
preoccupations)
 Idiosyncratic perceptual experiences or bodily illusions
 Odd thinking and speech (e.g., vague, circumstantial,
metaphorical, over-elaborate, or stereotyped speech)
 Suspiciousness or paranoid ideation
 Inappropriate or constricted affect
 Behavior or appearance that is odd, eccentric or peculiar
 Lack of close friends or confidants other than first-degree
relatives
 Excessive social anxiety that does not diminish with familiarity
and tends to be associated with paranoid fears rather than
negative judgments about self.

 Summarily, Schizotypal
personality, like the schizoid
personality, involves social
withdrawal and emotional
coldness but also includes
oddities of
thinking, perception, and
communication, such as magical
thinking, clairvoyance, idea of
reference, or paranoid ideation.
These oddities suggest
schizophrenia but are never
severe enough to meet its
criteria. People with schizotypal

CLUSTER B– Dramatic Emotional
Type
 This cluster includes
histrionic, narcissistic, antisocial, and borderline
personality disorders. Affected individuals tend to use
certain defense mechanisms such as
dissociation, denial, splitting, and acting out.
 Dissociation involves the “forgetting” of unpleasant
feelings and associations. It is the unconscious splitting
off of some mental processes and behavior from the
normal or conscious awareness of the individual. When
extreme, this can lead to multiple or disorganized
personalities.
 Denial is closely associated with dissociation. In
denial, patients refuse to acknowledge a
thought, feeling, or wish but are unaware of doing so.

CLUSTER B– Dramatic Emotional
Type
 Splitting, often seen in patients with borderline
personalities, occurs when these individuals view other
persons as “all good” or “all bad”. Affected patients cannot
experience an ambivalent relationship and cannot even be
ambivalent in regard to their own self-image.
 Acting out involves the actual motor expression of a thought
or feeling that is intolerable to a patient, this can involve both
aggressive and sexual behavior. Patients with these types of
personality disorders may be biologically vulnerable to stress
(i.e., a tendency to low cortical arousal causes them to easily
over-stimulate) and a wide variation of autonomic and motor
activities. Thus, a psychobiologic pattern may develop, which
increases the potential for acting out that is not associated
with any particular anxiety.
 Mood disorders are common and may be the chief
complaint. Somatization disorder is associated with
histrionic personality disorder.
 Patients tend to be emotionally unstable, impulsive, and
intense.

Cluster B – Borderline
 The central feature of borderline personality disorder is a
pervasive pattern of unstable and intense interpersonal
relationships, self-perception, and moods. Impulse control
is markedly impaired.
 Transiently, such patients may appear psychotic because
of the intensity of their distortions.
 Borderline personality disorder is one of the most
commonly overused diagnoses in DSM-IV.
 Diagnostic criteria require at least 5 of the following
features:
 Frantic efforts to avoid expected abandonment;
 Unstable and intense interpersonal relationships
characterized by alternating between extremes of

 Identity disturbance, that is, markedly and persistently
disturbed, distorted, or unstable self-image or sense
of self
 Impulsivity in at least 2 areas that are potentially self-
damaging (e.g., sex, substance abuse, reckless
driving)
 Recurrent suicidal behaviors or threats or self-
mutilation behavior
 Affective instability due to a marked reactivity of mood
 Chronic feelings of emptiness
 Inappropriate and intense anger or lack of control of

 This disorder may be present in 1-2 % of the
population. The diagnosis is made twice as frequently
in women. Of the individuals with this diagnosis 90 %
also have one of other psychiatric diagnosis and 40 %
have two other diagnoses.
 Summarily, borderline personality disorder is marked
by unstable self-image, mood, behavior, and
relationships. Affected people are often hypertensive;
they tend to believe they were deprived of adequate
care during childhood and consequently feel empty,
angry, and entitled to nurturance. As a result, they
relentlessly seek care and are sensitive to its
perceived absence. Their relationships tend to be
intense and dramatic. When feeling cared for, they
appear like lonely waifs who seek help for depression,
substance abuse, eating disorders, and past
mistreatments.

 When they fear the loss of the caring person, they
frequently express inappropriate intense anger. These
mod shifts are typically accompanied by extreme by
extreme changes in their views of the
world, themselves, and other people – e.g. from bad to
good, from hated to loved. When they feel
abandoned, they dissociate or become desperately
impulsive. Their concept of reality is sometimes so poor
that they have brief episodes of psychotic thinking, such as
paranoid delusions and hallucinations. They often become
self-destructive and may cut themselves (self-mutilate) or
attempt suicide. They initially tend to evoke
intense, nurturing responses on caretakers, but after
repeated crises, vague unfounded complaints, and failure
to adhere to therapeutic recommendations, they are
viewed as help-rejecting complainers.
 Borderline personality tends to become milder or to

Cluster B – Narcissistic
 A pervasive pattern of grandiosity, need for admiration, and
a lack of empathy. Characterized by self-
importance, preoccupations with fantasies, belief that they
are special, including a sense of entitlement and a need
for excessive admiration, and extreme levels of jealousy
and arrogance.
 Individuals have a grandiose sense of their own
importance but are also extremely sensitive to criticism.
They have little ability to empathize with others, and they
are more concerned about appearance than
substance. Narcissistic patients have a pervasive pattern
of grandiosity, need for admiration, and lack of empathy
that begins in early adulthood and is present in a variety of
contexts. Narcissistic personality disorder is indicated by
at least 5 of the following:
 A grandiose sense of self-importance (e.g., exaggeration
of achievements and talents, expectation for recognition
as superior without commensurate achievements)

 Preoccupation with fantasies of unlimited
success, power, brilliance, beauty, or ideal love
 Belief that she is “special” and unique and can only be
understood by, or should associate with, other special or
high-status people (or institutions)
 Requirement for excessive admiration
 A sense of entitlement (i.e., unreasonable expectations
of especially favorable treatment or automatic
compliance with her views)
 Behavior that is interpersonally exploitative (i.e., takes
advantage of others as a means to achieve her own
ends)
 Lack of empathy (i.e., unwilling to recognize or identify
with the feelings and needs of others)

 Jealousy or belief that others are envious of her
 Arrogance, demonstration of haughty behavior or
attitude
 Summarily, Narcissistic personality involves
grandiosity. Affected individuals have an exaggerated
sense of superiority and expect to be treated with
deference and preference. Their relationships are
characterized by a need to be admired, and they are
extremely sensitive to criticism, failure, or defeat.
When confronted with a failure to fulfill their high
opinion of themselves, they can become enraged or
seriously depressed and suicidal. The often believe
other people envy them. They may exploit other

Cluster B – Histrionic
 Excessive emotionality and attention-seeking behavior.
 Patients with histrionic personality disorder display
excessive emotionality and attention-seeking behavior.
They are quite dramatic and often sexually provocative or
seductive. Their emotions are labile.
 In clinical settings, their tendency to vague and
impressionistic speech is often highlighted. The
disorder was formerly called “hysterical personality”,
but that term was discarded because of the many
meanings of the word “hysterical”. A pervasive pattern of
excessive emotionality and attention seeking that begins
by early adulthood and is present in a variety of contexts is
characteristic. Histrionic personality disorder is indicated
by at least 5 of the following:
 Feeling of discomfort in situations in which she is not the
center of attention
 Interaction with others that is often characterized as
inappropriately sexually seductive of provocative

 Insincere affect (i.e., display of rapidly shifting and shallow
expression of emotions)
 Consistent use of physical appearance to draw attention to
herself
 Speech that is excessively impressionistic and lacking in
detail
 Self-dramatization, with a theatrical and exaggerated
expression of emotion
 Suggestibility (i.e., easily influenced by others or
circumstances)
 Exaggeration of importance of relationships and
acquaintances
 The prevalence of histrionic personality disorder is not
known with certainty. The condition, which is
thought to be common, is diagnosed in women
much more often than in men. Men who exhibit

 Summarily, Histrionic personality involves
conspicuous attention seeking. Affected people
are also overly conscious of appearance and are
dramatic. Their expression of emotions often
seems exaggerated, childish, and superficial. Still,
they frequently evoke sympathetic or erotic
attention from other people. Relationships are
often easily established and overly sexualized but
ten to be superficial and transient. Behind their
seductive behaviors and their tendency to
exaggerate somatic problems (i.e. hypochondria)
often lie more basic wishes for dependency and

Cluster B – Antisocial
 Chronic maladaptive behavior that disregards the rights of others.
 Individuals with antisocial personality disorder display a pervasive pattern
of disregard for and violation of the rights of others and the rules of
society. Individuals have a history of continuous and chronic antisocial
behavior in which the rights of others are violated.
 The essential defect is one of character structure in which affected
individuals are seemingly unable to control their impulses and
postpone immediate gratification.
 Affected individuals lack sensitivity to the feelings of others. They are
egocentric, selfish, and excessively demanding, in addition, they are
usually free of anxiety, remorse, and quilt.
 Violation of the law and customs of the local community is
characteristic. The terms “sociopath” and “psychopath” have been
applied to individuals with particularly deviant antisocial personalities.
 Personality disorders are considered lifelong conditions, and the signs
of conduct disorder must be present in adolescence. The criteria for
conduct disorder should be met.
 Persons who use illegal substances satisfy many of the criteria of
antisocial personality disorder as a result of their pursuit of these
substances. However, the diagnosis of antisocial personality disorder
is not appropriate if the only diagnostic criteria are all drug related and

 Factors indicative of antisocial personality disorder include:
 Current age of 18 years or older
 Evidence of a conduct disorder with onset before age 15
 A pervasive pattern of disregard for and violation of the rights of
others occurring since age 15, as indicated by at least 3 of the
following:
 Failure to conform to social norms with respect to lawful
behaviors as indicated by repeatedly performing acts that are
grounds for arrest
 Irritability and aggressiveness, as indicated by repeated physical
fights or assaults
 Consistent irresponsibility, as indicated by repeated failure to
sustain consistent work behavior or honor financial obligations
 Impulsivity or failure to plan ahead
 Deceitfulness, as indicated by repeated lying, use of aliases, or
conning others for personal profit or pleasure
 Reckless disregard for safety of self or others
 Lack of remorse, as indicated by being indifferent to or
rationalizing having hurt, mistreated, or stolen from another
person

 Summarily, Antisocial personality is marked by the
callous disregard for the rights and feelings of other
people. Affected people exploit others for materialistic
gain or personal gratification. They become frustrated
easily and tolerate frustration poorly.
Characteristically, they act out their conflicts
impulsively and irresponsibly, sometimes with hostility
and violence. They usually do not anticipate the
consequence of their behaviors and typically do not
feel remorse or guilt afterwards. Many of them have a
well-developed capacity for glibly rationalizing their
behavior or blaming it on others. Dishonesty and
deceit permeate their relationships. Punishment rarely
modifies their behavior or improves their judgment.
Antisocial personality often leads to alcoholism, drug
addiction, promiscuity, failure to fulfill
responsibilities, frequent relocation, and difficulty

Cluster C – Anxious and Fearful
Type
 This group includes avoidant, dependent, and obsessive-
compulsive personalities. Affected individuals use defense
mechanisms of isolation, passive-aggression, and
hypochondriasis.
 Isolation occurs when an unacceptable feeling, act, or idea is
separated from the associated emotion. Patients are orderly
and controlled and can speak of events in their lives without
feeling.
 Passive-aggression occurs when resistant is indirect and
often turned against the self. Thus, failing
examinations, clownish conduct, and procrastinating are
aspects of passive-aggressive behavior.
 Hypochondriasis is often present in patients with personality
disorders, particularly in dependent, passive-aggressive
patients. Biologically, these patients may have a tendency
toward higher levels of cortical arousal and an increase in
motor inhibition. Thus, stressful stimuli may lead to high

Cluster C – Anxious and Fearful
Type
 Twin studies have
demonstrated some genetic
factors in the development
of cluster C personality
disorders. For example,
obsessive-compulsive traits
are more common in
monozygotic twins than in
di-zygotic twins. Patients
with obsessive-compulsive
disorder are not at
increased risk for
obsessive-compulsive
personality disorder and

Cluster C – Avoidant
 Avoidant patients are generally very shy. They display a
pattern of social inhibition, feelings of inadequacy, and
hypersensitivity to rejection. Unlike patients with schizoid
personality disorder, they actually desire relationships with
others but are paralyzed by their fear and sensitivity into
social isolation.
 A pervasive pattern of social inhibition, feelings of
inadequacy, and hypersensitivity to negative evaluation
that began by early adulthood is indicative.
 Avoidant personality disorder, which is present in a variety
of contexts, is indicated by at least 4 of the following:
 Avoidance of occupational activities that involve significant
interpersonal contact, because of fears of criticism,
disapproval, or rejection
 Unwillingness to become involved with people unless certain
of being liked.

Cluster C - Avoidant
 Restraint in intimate relationships because of fear of being shamed
or ridiculed
 Preoccupation with worry about being criticized or rejected in social
situations
 Inhibition in new interpersonal situations because of feelings of
inadequacy
 Belief that he is socially inept, personally unappealing, or inferior to
others
 Unusual reluctance to take personal risks or engage in any new
activities because they may prove embarrassing
 Avoidant Personality Disorder, APD is closely linked to a
person’s temperament. Approximately 10% of toddlers have
been found to be habitually fearful and withdrawn when
exposed to new people and situations.
 This trait appears to be stable over time.
 Social anxiety is hypothesized to involve the amygdala and
other areas of the brain’s limbic system, which, in affected
individuals, is postulated to have a lower threshold of arousal
and a more pronounced response when activated.

Cluster C - Avoidant
 Summarily, Avoidant personality is marked by
hypersensitivity to rejection and fear of starting
relationships or anything new because of the risk of
failure or disappointment. Because affected people
have a strong conscious desire for affection and
acceptance, they are openly distressed by their
isolation and inability to relate comfortably to other
people. They respond to even small hints of rejection
by withdrawing.

Cluster C – Obsessive-
Compulsive
 People with obsessive-compulsive personality disorder are
markedly preoccupied with orderliness, perfectionism, and
control. They lack flexibility or openness. Their preoccupations
interfere with their efficiency despite their focus on tasks. They
are often scrupulous and inflexible about matters of
morality, ethics, and values to a point beyond cultural norms.
They are often stingy as well as stubborn.
 Individuals with obsessive-compulsive personality disorder
display a pervasive pattern of preoccupation with
orderliness, perfectionism, and environmental and interpersonal
control, at the expense of flexibility, openness, and efficiency.
This behavior begins by early adulthood and is present in a
variety of contexts, as indicated by at least 4 of the following:
 Preoccupation with details, rules, lists, order, organization, or
schedules to the extent that the major point of the activity is lost
 Perfectionism that interferes with task completion (e.g., inability to
complete a project because one’s own overly strict standards are
not met)

Compulsive
 Excessive devotion to work and productivity to the exclusion of
leisure activities and friendships (not accounted for by obvious
economic necessity)
 Over-conscientiousness, scrupulousness, and inflexibility about
matters of morality, ethics, or values (not accounted for by cultural or
religious identification)
 Inability to discard worn-out or worthless objects even when they
have no sentimental value
 Reluctance to delegate tasks or to work with others unless they
submit to exactly his way of doing things
 Adoption of a miserly spending style toward both herself and others
(money is viewed as something to be hoarded for future
catastrophes)
 Rigidity and stubbornness
 People with this disorder have few friends. They are difficult to
live with and tend to drive people away. They may do very well
in jobs that require detail and precision with little personal
interaction. This disorder is more common in men, although the
prevalence is not known with certainty.

Compulsive
 Summarily, Obsessive-compulsive personality is
characterized by conscientiousness, orderliness, and
reliability, but inflexibility often makes affected people
unable to adapt to change. They take responsibilities
seriously, but because they hate mistakes and
incompleteness, they can become entangled with details
and forget their purpose. As a result, they have difficulty
making decisions and completing tasks. Such problems
make responsibilities a source of anxiety, and they rarely
enjoy much satisfaction from their achievements. Most
obsessive-compulsive traits are adaptive, and as long as
they are not too marked, people who have them often
achieve much, especially in the sciences and other
academic fields in which order, perfectionism and
perseverance are desirable. However, they can feel
uncomfortable with feelings, interpersonal
relationships, and situations in which they lack
control, they must rely on other people, or events are

Cluster C – Dependent
 While many people exhibit dependent behaviors and traits,
people with dependent personality disorder have an
excessive need to be taken care of that results in
submissive and clinging behavior, regardless of
consequences. These passive individuals allow others to
direct their lives because they are unable to do so
themselves. Other people such as spouses or parents
make all the major life decisions, including where to live
and what type of employment to obtain.
 The needs of dependent individuals are placed secondary
to those of the people on whom they depend to avoid any
possibility of having to be self-reliant.
 The dependent persons lack self-confidence and see
themselves as helpless or stupid.
 Some authorities believe that the presence of this
disorder depends to a large extent on cultural roles.

Cluster C - Dependent
 Diagnosis requires at least 5 of the following features:
 Inability to make everyday decisions without an
excessive amount of advice and reassurance from
others
 Need for others to assume responsibility for most
major areas of the person's life
 Difficulty expressing disagreement with others
because of fear of loss of support or approval
 Difficulty initiating projects or doing things on his own
because of lack of confidence
 Goes to excessive lengths to obtain nurturance and
support from others, to the point of volunteering to
do things that are unpleasant

 Feelings of discomfort or helplessness when alone
because of exaggerated fears of being unable to
care for himself
 Urgent seeking of another relationship as a source
of care and support when a close relationship ends
 Unrealistic preoccupation with fears of being left to
take care of himself
 Children who have a chronic physical illness or who have
had separation anxiety may be at risk for this disorder in
adulthood. The diagnosis is more frequent in women and
youngest children.

 Summarily, Dependent Personality is characterized by the
surrender of responsibility to other people. Affected people
may submit to others to gain and maintain support. For
example, they often allow the needs of people they
depend on to supersede their own. They lack self-
confidence and feel intensely inadequate about taking care
of themselves. They believe that others are more
capable, and they are reluctant to express their view for
fear that their aggressiveness will offend the people they
need. Dependency in other personality disorders may be
hidden by obvious behavioral problems; e.g., histrionic or
borderline behavior mask underlying dependency.

PERSONALITY DISORDERS
NOT SPECIFIED

Personality disorders not
specified
 Several other personality types have been described
but are not classified as disorders in the DSM-IV-TR.
This includes:
 Passive-aggressive (negativistic) personality – is a
pattern of negative attitudes and passive resistance in
interpersonal situations which typically produce the
appearance of ineptness or passivity, but these
behaviors are covertly designed to avoid responsibility
or to control or punish other people. Passive-
aggressive behavior is often evidenced by
procrastination, inefficiency, or unrealistic protests of
disability. Frequently, affected individuals agree to do
tasks they do not want to do and then subtly
undermine completion of the tasks. Such behavior
usually serves to deny or conceal hostility or

specified
 Cyclothymic personality – alternates between high-
spirited buoyancy and gloomy pessimism; each mood
lasts weeks or longer. Characteristically, the rhythmic
mood changes are regular and occur without
justifiable external cause. When these features do not
interfere with social adaptation, cyclothymia is
considered a temperament and is present in many
gifted and creative people.

specified
 Depressive personality – is a pervasive pattern of
depressive cognitions and behaviors beginning by
early adulthood. It is characterized by chronic
moroseness, worry, and self-consciousness. Affected
individuals have a pessimistic outlook, which impairs
their initiatives and disheartens other people. Self-
satisfaction seems undeserved and sinful. They
unconsciously believe their suffering is a badge of
merit needed to earn the love or admiration of others.

specified
 Sadistic personality – Sadism is a behavioral
disorder characterized by a
callous, vicious, manipulative, and degrading behavior
expressed towards other people. To date, the exact
cause of sadism is not known clearly. However, many
theories have been given to explain the possible
reasons underlying the development of a sadistic
personality in an individual.
 Most of these theories commonly point out the fact
that sadism is mainly dependent on the upbringing of
an individual. Although biological and environmental
aspects are also known to contribute to the
development of this behavioral disorder, less evidence

specified
 Self-defeating personality – also known as masochistic
personality disorder, according to the Proposed DSM-III, it is
characterized by the following criteria:
 A pervasive pattern of self-defeating behavior, beginning by
early adulthood and present in a variety of contexts. The person
may often avoid or undermine pleasurable experiences, be
drawn to situations or relationships in which he or she will suffer,
and prevent others from helping him, as indicated by at least
five of the following: chooses people and situations that lead to
disappointment, failure, or mistreatment even when better
options are clearly available
 rejects or renders ineffective the attempts of others to help him or
her
 following positive personal events (e.g., new achievement),
responds with depression, guilt, or a behavior that produces pain
(e.g., an accident)
 incites angry or rejecting responses from others and then feels hurt,
defeated, or humiliated (e.g., makes fun of spouse in public,
provoking an angry retort, then feels devastated)

specified
 rejects opportunities for pleasure, or is reluctant to
acknowledge enjoying himself or herself (despite having
adequate social skills and the capacity for pleasure)
 fails to accomplish tasks crucial to his or her personal
objectives despite demonstrated ability to do so, e.g., helps
fellow students write papers, but is unable to write his or her
own
 is uninterested in or rejects people who consistently treat him
or her well, e.g., is un-attracted to caring sexual partners
 engages in excessive self-sacrifice that is unsolicited by the
intended recipients of the sacrifice
 The behaviors described above do not occur exclusively in
response to, or in anticipation of, being
physically, sexually, or psychologically abused.
 The behaviors described above do not occur only when
the person is depressed.

Differential Diagnosis
 For the sake of simplicity, it is explicit to describe the
differential diagnosis under the following heading:
 Medical
 Psychiatric

Differential diagnosis – Medical
 Mental Retardation secondary to medical condition or
neurologic deficit
 Alcoholism

Differential diagnosis – Psychiatric
 Alcoholism
 Anxiety Disorders
 Brief Psychotic Disorder
 Bulimia
 Depression
 Dissociative Disorders
 Ganser Syndrome
 Hypochondriasis
 Mental Disorders Secondary to General Medical Conditions
 Paraphilias
 Posttraumatic Stress Disorder
 Schizoaffective Disorder
 Schizophrenia
 Schizophreniform Disorde
 Social Phobia

Investigations
 Toxicology screen: Substance abuse is common in many
personality disorders, and intoxication can lead patients to
present with some features of personality disorders.
 Screening for HIV and other sexually transmitted diseases:
Patients with personality disorders often exhibit poor
impulse control and many act without regard to risk.
 Psychological testing may support or direct the clinical
diagnosis.
 The Minnesota Multiphasic Personality Inventory (MMPI) is
the best-known psychological test. The Eysenck Personality
Inventory and the Personality Diagnostic Questionnaire are
also used. None of these has been reliably validated against
DSM-IV-TR diagnoses.
 The Structured Clinical Interview for DSM-IV-TR for Axis II
Disorders (SCID-II) can also be used to aid in diagnosis.

DSM IV CRITERIA FOR
PERSONALITY
DISORDERS

DSM IV Criteria for Personality
Disorders
 DSM-IV-TR Criteria for Paranoid Personality Disorder:
Presence of four or more of the following and not occurring
exclusively during a course of schizophrenia, psychotic
depression, or as part of a pervasive developmental disorder;
also not due to a general medical condition:
 Pervasive suspiciousness of being harmed, deceived, or
exploited
 Unwarranted doubts about the loyalty or trustworthiness of
friends or associates
 Reluctance to confide in others because of preceding criterion
 Hidden meanings read into the innocuous actions of others
 Grudges for perceived wrongs
 Angry reactions to perceived attacks on character or
reputation
 Akin to first two criteria, unwarranted suspiciousness of the

Disorders
 DSM-IV-TR Criteria for Schizoid Personality Disorder:
Presence of four or more of the following and not occurring
depression, or as part of a pervasive developmental
disorder; also not due to a general medical condition:
 Lack of desire or enjoyment of close relationships.
 Almost exclusive preference for solitude
 Little interest in sex with others
 Few, if any, pleasures
 Lack of friends
 Indifference to praise or criticism from others
 Flat affect, emotional detachment

Disorders
 DSM-IV-TR Criteria for Schizotypal Personality Disorder:
Presence of five or more of the following and not occurring
depression, or as part of a pervasive developmental
disorder; also not due to a general medical condition:
 Ideas of reference
 Peculiar beliefs or magical thinking e:g., belief in extrasensory
perception
 Unusual perceptions e.g., distorted beliefs about one's body
 Peculiar patterns of speech
 Extreme suspiciousness, paranoia
 Inappropriate affect
 Odd behavior or appearance
 Lack of close friends
 Extreme discomfort and sometimes extreme anxiety around

Disorders
 DSM-IV-TR Criteria for Borderline Personality Disorder:
Presence of five or more of the following:
 Frantic efforts to avoid abandonment, both real and imagined
 Instability and extreme intensity in interpersonal
relationships, marked by splitting, that is, idealizing others in one
moment and reviling them the next
 Unstable sense of self
 Impulsive behavior, including reckless spending and sexual
promiscuity
 Recurrent suicidal (gestures as well as genuine attempts) and self-
mutilating behavior
 Extreme emotional liability
 Chronic feelings of emptiness
 Extreme problems controlling anger
 Paranoid thinking and dissociative symptoms triggered by stress

Disorders
 DSM-IV-TR Criteria for Histrionic Personality Disorder:
 Strong need to be the center of attention
 Inappropriate sexually seductive behavior
 Rapidly shifting expression of emotions
 Use of physical appearance to draw attention to self
 Speech excessively impressionistic, passionately held
opinions lacking in details
 Exaggerated, theatrical emotional expression
 Overly suggestible
 Misreads relationships as being more intimate than they
actually are.

Disorders
 DSM-IV-TR Criteria for Narcissistic Personality Disorder:
 Grandiose view of one’s importance, arrogance
 Preoccupation with one’s success, brilliance, beauty
 Extreme need for admiration
 Strong sense of entitlement
 Tendency to exploit others
 Envy of others

Disorders
 DSM-IV-TR Criteria for Antisocial Personality Disorder:
pervasive pattern of disregard for the rights of others since the
age of 15 and at least three of the characteristics 1 through 7
plus 8 through 10:
1. Repeated law-breaking
2. Deceitfulness, lying
3. Impulsivity
4. Irritableness and aggressiveness
5. Reckless disregard for own safety and that of others
6. Irresponsibility as seen in unreliable employment history or not
meeting finical obligations
7. Lack of remorse
8. Age at least 18
9. Evidence of conduct disorder before the age of 15
10. Antisocial behavior not occurring exclusively during
episodes of schizophrenia or mania

Disorders
 DSM-IV-TR Criteria for Avoidant Personality Disorder:
presence of at least four of the following:
 Avoidance of interpersonal contacts because of fears of criticism or
rejection
 Unwillingness to get involved with others unless certain of being
liked
 Restraint in intimate relationships for fear of being shamed or
ridiculed
 Preoccupation about being criticized or rejected
 Feelings of inadequacy
 Feelings of inferiority
 Extreme reluctance to try new things for fear of being embarrassed.

Disorders
 DSM-IV-TR Criteria for Obsessive-Compulsive Personality
Disorder: presence of at least four of the following:
 Preoccupation with rules and details to the extent that the major
point of an activity is lost
 Extreme perfectionism to the degree that projects are seldom
completed
 Excessive devotion to work to the exclusion of leisure and
friendships
 Difficulty discarding worthless items
 Reluctance to delegate unless others conform to one’s standard
 Miserliness
 Rigidity and stubbornness

Disorders
 DSM-IV-TR Criteria for Dependent Personality Disorder:
presence of at least four of the following:
 Difficulty making decisions without excessive advice and
reassurance from others
 Need for others to take responsibility for most major areas of life
 Difficulty disagreeing with others for fear of losing their support
 Difficulty doing things on own because of lack of self-confidence
 Doing unpleasant things as a way to obtain the approval and
support of others
 Feelings of helplessness when alone because of lack of confidence
in ability to handle things without the intervention of others
 Urgently seeking of new relationship when present one ends
 Preoccupation with fears of having to take care of self.

Treatment
 Treatment modality of MIMD will be discussed under
the following headlines:
 Psychological & Social – the gold standard
 Biological

Treatment – Psychological &
Social
 Psychotherapy is at the core of care for personality disorders.
Because personality disorders produce symptoms as a result of
poor or limited coping skills, psychotherapy aims to improve
perceptions of and responses to social and environmental
stressors.
 Psychodynamic psychotherapy examines the ways that patients perceive
events, based on the assumption that perceptions are shaped by early life
experiences. Psychotherapy aims to identify perceptual distortions and their
historical sources and to facilitate the development of more adaptive modes
of perception and response. Treatment is usually extended over a course of
several years at a frequency from several times a week to once a month; it
makes use of transference.
 Cognitive therapy (also called cognitive behavior therapy [CBT]) is
based on the idea that cognitive errors based on long-standing beliefs
influence the meaning attached to interpersonal events. It deals with how
people think about their world and their perception of it. This very active
form of therapy identifies the distortions and engages the patient in efforts
to reformulate perceptions and behaviors. This therapy is typically limited to
episodes of 6-20 weeks, once weekly. In the case of personality
disorders, episodes of therapy are repeated often over the course of years.

Treatment – Psychological &
Social
 Interpersonal therapy (IPT) conceives of patients' difficulties resulting
from a limited range of interpersonal problems including such issues
as role definition and grief. Current problems are interpreted narrowly
through the screen of these formulations, and solutions are framed in
interpersonal terms. Therapy is usually weekly for a period of 6-20
sessions. Though empirically validated for anxiety and depression, IPT
is not widely practiced, and therapists conversant in the technique are
difficult to locate.
 Group psychotherapy allows interpersonal psychopathology to
display itself among peer patients, whose feedback is used by the
therapist to identify and correct maladaptive
ideas, communication, and behavior. Sessions are usually once
weekly over a course that may range from several months to years.
 Dialectical behavior therapy (DBT): This is a skills-based therapy
(developed by Marsha Linehan, PhD) that can be used in both
individual and group formats. It has been applied to borderline
personality disorder. The emphasis of this manual-based therapy is on
the development of coping skills to improve affective stability and
impulse control and on reducing self-harmful behavior. This treatment

Treatment – Biological
 Medications are in no way curative for any personality disorder.
They should be viewed as an adjunct to psychotherapy so that
the patient may productively engage in psychotherapy.
 The focus is on treatment of symptom clusters such as
cognitive-perceptual symptoms, affective dysregulation, and
impulsive-behavioral dyscontrol. These symptoms may
complicate almost all personality disorders to varying degrees,
but all of them have been noted in borderline personality
disorder.
 The assumption is that neurotransmitter abnormalities underlie
these symptom clusters that transcend the concepts of Axis I
and Axis II disorders. The strongest evidence for pharmacologic
treatment of personality disorders has been for borderline
personality disorder, but even this is based on a fairly small
database of studies.
 Drug class commonly used includes:
 Antidepressant
 Antipsychotics
 Anticonvulsants

Complications
 Suicide
 Substance abuse
 Accidental injury
 Depression
 Homicide - A potential complication, particularly in
paranoid and antisocial personality disorders

Prognosis - overall
 Personality disorders are lifelong conditions.
 Attributes of cluster A and B personality disorders tend
to become less severe and intense in middle age and
late life.
 Patients with cluster B personality disorders are
particularly susceptible to problems of substance
abuse, impulse control, and suicidal behavior, which
may shorten their lives.
 Cluster C characteristics tend to become exaggerated
in later life.

Prevention
 Within the limits of contemporary medical
knowledge, personality disorders cannot be prevented, although
steps can be taken to prevent or deter some of the
consequences and complications of personality disorders.
 Frequent inquiries about suicidal ideation are
warranted, regardless of whether the patient spontaneously
raises the subject. The physician need not fear instilling the idea
of suicide in a patient who is not already entertaining it.
Subsequent inquiry about firearms, lethal medications, and
other available means of suicide point to avenues of preventive
behavior.
 Benzodiazepines, narcotic analgesics, and other drugs with
potential for dependency should be used rarely and with great
caution. Nearly all personality disorders are marked by impaired
impulse control and consequent risk of addictive behavior.
 Patients with personality disorder who have children should be
asked frequently and in detail about their parenting practices.
Their low frustration tolerance, externalization of blame for
psychological distress, and impaired impulse control put the
children of these patients at risk for neglect or abuse.

References
 http://emedicine.medscape.com/article/1151826-overview#a7
 http://emedicine.medscape.com/article/805930-overview#a1
 http://emedicine.medscape.com/article/294307-overview
 http://psychology.about.com/od/personalitydevelopment/a/personality-
dev.htm
 Mayo Foundation for Medical Education and Research
 Kaplan videos – General principles of Personality Disorders
 http://www.mayoclinic.com/health/personality-
disorders/ds00562/dsection=causes
 http://www.apa.org/topics/personality/disorders-causes.aspx
 http://www.at-risk.org/blog/962/teen-paranoid-personality-disorder/
 Prof. Shuctov’s lecture on Personality Disorder, Psychiatric Department:
Ryazan State .I.P. Pavlov Medical University, Russia.
 http://www.ivcc.edu/uploadedFiles/_faculty/_mangold/Personality%20Dis
orders%20in%20the%20DSM.pdf
 http://en.wikipedia.org/wiki/Personality_disorder
 http://en.wikipedia.org/wiki/Self-defeating_personality_disorder
 http://en.wikipedia.org/wiki/Sadistic_personality_disorder

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