Personality Disorders

Overview

Personality disorders are an enduring pattern of inner experience and behavior, that, as a whole, deviates markedly from the culturally expected and accepted range. It is less of a disorder, and more of an enduring set of behavioural traits. They do not just present in the clinic. People with personality disorders don’t see the problem in themselves (they are ego syntonic). The degree of maladaptiveness results in difficulties in interactions over time (not being able to form relationships, getting fired, losing friends etc.) that makes the patient come in for anxiety, depression etc. Personality disorders are difficult to treat. They may predispose the patient to comorbid psychiatric disorders. CBT and insight-oriented individual psychotherapy are almost always the treatment of choice.

At least 5% of individuals in the commonity have a diagnosable personality disorder (if unspecified or mixed pD is included at least 10% have a personality disorder. Obsessive-compulsive PD is the most frequent type followed by narcissistic PD. Boderline PD is more common in the psychiatric setting. Antisocial PD is more common in prisons.

Dimensional Model for Personality Disorders (DSM-V): Included in Section III (issues that need further research) in the DSM 5. Outlines 25 maladaptive traints that are divided into 5 domains – negative affectivity, detachment, antagonism, disinhibition, and psychoticism. These 5 domains appear to be reliable and valid in predicitng funcitonal impairment in personality disorders.

Overview of Personality Disorders

Personality Disorder	DSM-V	ICD-10
Paranoid	Cluster A	Yes
Schizoid	Cluster A	Yes
Schizotypal	Cluster A	Under Psychotic Disorders
Boderline	Cluster B	A subtype of Emotionally Unstable PD (has impulsive and boderline type)
Antisocial	Cluster B	Dissocial PD
Histrionic	Cluster B	Yes
Narcissistic	Cluster B	In Annex 1
Obsessive-Compulsive	Cluster C	Anakastic PD
Dependent	Cluster C	Yes
Avoidant	Cluster C	Yes (Anxious/Avoidant PD)
Passive Aggressive		In Annex 1

3 Clusters of personality disorders (DSM-V)

Cluster	Disorders	Nota bene
Cluster A Personality Disorders (Odd/Eccentric)	Paranoid PD, Schizoid PD, Schizotypal PD	Predisposed to schizophrenia and psychotic spectrum. Severity worsens from paranoid > Schizoid > schizotypal
Cluster B Personality Disorders (Dramatic/Emotional/Erratic)	Antisocial PD, Boderline PD, Histrionic PD, Narcissistic PD	Prone to develop mood disorders
Cluster C Personality Disorders (Fearful/Tearful/Neurotic)	Avoidant PD, Dependent PD, Obsessive Convulsive PD	Prone to develop anxiety and related disorders

Ego Syntonia vs Ego Dystonia

Term	Description
Ego Syntonia	The patient is unaware that their behaviour is problematic. Personality disorders are usually ego syntonic
Ego Dystonia	The patient is aware that their behaviour is problematic

Epidemiology of personality disorders

Gender	Common Personality disorder
Males	Schizoid, paranoid, antisocial, narcissistic, avoidant
Females	Boderline, histrionic, dependent
Both	Schizotypal, obsessive-compulsive

Psychological Theories of Personality

Normothetic vs Idiographic theories of personality

Term	Definition
Normothetic theories	Talk about universal traits and dimensions of personality that are present in varying degrees throughout the population
Idiographic theories	Deal with the uniqueness of individual personalities

Pioneers in the field of personality

Pioneer	Contribution
Hans Eysenck (1916 – 1997)	Describe the ‘Gigantic Three’ – Neuroticism, Extraversion and Pscyhoticism
Raymond Cattel (1905 – 1998)	Using factor analysis he listed 16 primary personality traints. From these 16, 5 secondary factors (’Big Five’) were identified – Neuroticism, Extroversion, Openness to experience, Conscientiousness, and Agreeableness. He developed the 16 PFQ.
Gordon Allport (1897 – 1967)	Pioneered idiographic theory of personality, emphasizing the uniquenss of every individual. He describe 3 types of traits in each person – Cardinal Trait, Central Trait and Secondary Trait

Type A and B Personality (describe by Meyer Freidman and Ray Rosenman based on their observations of the behaviors of their patients in the waiting room)

Personality	Description
Type A	Impatient, sitting on the edge of their seats. Initial research suggests a higher risk of CAD. Now called type A behavior pattern (TABP)
Type B	More laid-back (literally)

• Characteristics of Type A personality (TABP)
  • HIgh degree of competitiveness or ambition
  • Sense of time urgency or impatience
  • Self-cricicism or criticism of others
  • Hostility of aggression
  • Inability to relax
  • Inability to delay actions
• Characteristics of Type B Personality
  • Relaxed
  • Laid back
  • Not competitive
  • Prefer creative occupations
  • Reflect more before acting
  • Tendency to procrastinate

Etiology of Personality Disorder

Underlying psychodynamics in personality disorders

Personality disorder	Underlying psychodynamics
Paranoid PD	Defense mechanism of projection
Schizoid PD	Emotional detachment serves the purpose of helping to avoid emotional pain
Schizotypal PD	Escapes from reality by fantasizing
Boderline PD	Splitting, projection, projective identification and dissociation
Antisocial PD	Denial, acting out, and externalisation
Narcissstic PD	Denial, omnipotence, reaction formation. The fragile self-esteem is compenseted by exaggerated self-importance
Histrionic PD	Regression, somatization
Obsessive compulsivre PD	Fixation at the anal stage of development. Defence mechanism of reaction formation and magical undoing
Avoidant PD	Fixation at the oral stage of development. Over-controlling/over-protective parantes and early childhood attachment problems
Dependent PD	Defense mechanisms of regression, idealizaiton fo others and devaluation of self may be relevant.

• Etiology of personality disorders
  • Genetics: plays a greater role in some personality disorders e.g. schizotypal PD
  • History of adverse childhood events e.g. sexual, physica, emotional or verbal abuse or neglect: risk factor for boderline PD
  • Growing up in a family with criminal offenders: risk factor for conduct disorder and subsequent antisocial PD
  • Children who display ‘high reactivitity’ (excessive sensitivity to noise, light etc): risk factor for developing cluster C (anxious) personality disorder
  • Having a trusting, strong relationship with parents in childhood is protective agaisnt developing personality disorder in the future

Assessment of Personality Disorders

The onset of personality disorders is early and the features are persistent and stable, while in function mental disorders the onset is usually later and symptoms tend to be episodic.

Personality disorder vs. personality trait

Term	Definition
Personality disorder	An aggregate of abnormal personality traits. Only when these traits reach a certain threshold in number, severity or impairment is the term personality disorder used.
Personality trait	A single aspect of one’s personality trait. Most people have isolated personality traits. An abnormal trait does not automatically mean a person has a personality disorder. Traits are longstanding and stable e.g. emotional instability of boderline PD, avoidance of avoidant PD and social withdrawal of schizoid PD.
State	States are episodic and represent a clear change from the person’s usual pattern of thinking, feeling and behavior e.g. emotional instability of bipolar disorder, avoidance seen in phobias, and social withdrawal in depression.

Differential diagnoses of personality disorders

Personality disorder	Differentials
Schizoid PD	Depression, negative symptoms of schizophrenia, simple schizophrenia, autism spectrum disorder
Schizotypal PD	Schizophrenia, unspecified psychosis
Paranoid PD	Persistent delusional disorder, paranoid schizophrenia
Boderline PD	Cyclothymia, bipolar disorder (mixed state), rapic cycling bipolar disorder, adult ADHD, acute transient psychosis

• Sources of information regarding a patient’s personality
  • Personal history
  • Patient’s opinion of his/ her own personality (gives an account of their own personality and predict what others would say of him/ her)
  • Family and friends’ opinions
  • The interview situation: observation by the clinician
• Assessment instruments for personality disorders (mainly used in psychology research studies and not in routine clinical practice)
  • Minnesota Multiphasic Personalty Inventory (MMPI)
  • Myers-Briggs Type Indicator (MBTI)
  • Cttell’s 16 Personalty Factor Questionnaire (16 PFQ)
  • Eysenck Personality Inventory (EPI)
  • International Personality Disorder Examinatoin (IPDE)
  • Projective tests: Rorschach inkblot test, Thematic Apperception Test, Make a picture test, Sentence completion
• Biological investigations
  • EEG: abnormal waves in antisocial and boderline
  • Platelet MAO
  • Hormone levels

Paranoid Personality Disorder

Paranoid PD is characterised by long-standing mistrust and suspicion of others. May have schizoid features like isolation (because of suspicion).

M > W. Worsens with age.

• Features
  • Deep cynicism
  • Slow to forgive (Always bear grudges)
  • Quick to reference conspiracy
  • Pathologically jealous and argumentative
  • Self-referential attitude
  • Suspicions of infidenlity of their spouse
  • Excessive sensitivity to criticism and setbacks
• Associated conditions
  • Delusional disorder
  • Major Depressive Disorder: There is an increased risk of MDD since these patients have a small network of support because of difficulty forming friends
  • Psychotic episodes: seen with severe stress and psychologically traumatic events. Treated with antipsychotics
• Differentials
  • Delusional disorder, persecutory type – Delusional disorder centres around a specific delusion; Paranoid PD delusions is generalized (spans their entire life, friends, work etc.)
  • Schizophrenia: there is psychotic and/or disorganized thinking
• Treatment
  • Insight oriented individual psychotherapy
  • Treat psychotic episodes with antipsychotics

Schizoid Personality Disorder

In schizoid personality disorder, the patient is a loner. There are pseudo psychotic symptoms (illusions, overvalued ideas, or ideas of reference). They find discomfort in social interactions. It is less common and patients tend not to present. It can eventually lead to severe schizophrenia

• Features
  • Introverted
  • Prefers isolation
  • Reduced/Blunted affect
  • Anhedonia
  • Limited desire for friends or relationships (lack intimacy, can more attached with animals)
  • Indifferent to praise or criticism
  • Decreased emotional understanding
  • Clairvoyance, telepathy, can predict the future
  • Can speak in tongues (has features of a “Mganga”)
  • Unintentional disregard for social norms
• Differentials
  • Social anxiety disorder: SAD will want to have social interactions but are fearful because of embarrassment and anxiety
  • Major depressive disorder: MDD will have sleep disturbances, suicidality/suicidal ideation, feelings of guilt
  • Asperger’s syndrome: symptoms in peds and other autism spectrum disorder traits (reduced ability to understand non-verbal communication, repetitive activity, idiosyncratic prosody)
  • Avoidant personality disorder: will desire social interaction, but are fearful due to perceived inferiority
• Treatment
  • Insight-oriented psychotherapy

Schizotypal Personality Disorder

In schizotypal personality disorder, the patient has odd thoughts. These thoughts need to be differentiated from the patient’s cultural/religious ideals.

• Features
  • Odd behaviour
  • Odd appearance
  • Constricted affect (appears aloof and cold)
  • Magical thinking
  • Superstitious
  • Social anxiety or isolation (because they fear people)
  • Ruminaitons involving violent or sexual themes
  • Depersonalization/ Derealization/ Illusions
  • Transient quasi-psychotic episodes
• Though process and content in a patient with schizotypal personality disorder
  • Coherent.
  • But may be boderline bizzare/delusional.
  • These odd thoughts make them fearful of people
• Associated conditions
  • Psychotic episodes: can occur during stress or psychologically traumatic events
  • “Schizophrenia spectrum”: Think of schizotypal PD as being in a spectrum with schizophrenia. Though patients with schizotypal PD have no difficulty functioning in their daily lives. They may have first-degree relatives with schizophrenia
• Differentials
  • Schizophrenia: prominent psychotic thoughts. A lesser degree of function.
  • Social anxiety disorder: SAD is a fear of embarrassment around people while Schizotypal PD is an actual fear of people
  • Schizoid PD: will not display odd thoughts and behaviour
• Treatment
  • Insight-oriented psychotherapy

Antisocial Personality Disorder

In antisocial PD, patient has no regard for the rights of others. Psychopath = “Anti-society”. Most likely has a criminal record and an history of conduct disorder. Requires 18+ years of age for diagnosis. Symptoms soften with age (may be related to testosterone levels.

• Etiology of Antisocial PD
  • Parental criminal behavior, alcoholism, discord or single parenthood
  • Lack of parental supervision (especially in large families)
  • Childhood abuse
  • Some potential candidates genes e.g. MAO-A gene have been identified
  • Maternal smoking during pregnancy
  • General low arousal levels leading to risky activities in attempts to compensate
  • Lower resting heart rate
  • Reduced functioning of the brain’s right hemisphere
• Features
  • Low tolerance for frustration (repeated physical confrontations)
  • Tendency to blame others for one’s antisocial action
  • Low capacity for guilt
  • Lacks remorse (may rationalize why they did it)
  • Inability to learn from punishment
  • Can easily establish relationships but cannot maintain them
  • Repeated lying, using aliases or cheating others for profit or pleasure
  • Evidence of conduct disorder before age 15
• Associated conditions
  • Conduct Disorder: The pediatric “equivalent” of Antisocial PD
• Differentials
  • Intermittent explosive disorder: physical confrontations are isolated and appear once in a while. Intermittent, not pervasive
  • Conduct disorder: patients under 18 years of age
  • Neurodegenerative processes that affect the frontal lobe: Pick’s disease (Frontotemporal dementia), Huntington’s disease
  • Any medical condition that affects the frontal lobe
• Treatment
  • Insight-oriented psychotherapy

Borderline Personality Disorder

Patients with Boderline PD are emotionally unstable. It is at the border of neurosis and psychosis (“Ambulatory schizophrenia”).

More common in Women. Very very high risk of suicide. Keep an eye on developing mood disorders (75% lifetime risk). Substance abuse is common.

• Etiology of Boderline PD
  • Childhood sexual abuse
  • Other abuse and neglect during childhood
  • Parental psychopathlogy
  • Parental disocrd
  • Serotonin dysfunction (with regard to impulsivity). Dopamine and Noradrenaline dysfunciton may also play a role
  • HPA axis dysfunction
  • Hyperactivity of the amygdala and hypoactivity of the prefrontal cortex on neuroimaging
• Features
  • Impulsivity (can manifest in many ways and is episodic) e.g. alcohol, drugs, binge-eating, sex, spending and driving
  • Difficult interpersonal relationship (may become more secure with transitional objects e.g. pets, toys)
  • Unstable affect: intense anxiety/irritability that lasts usually for only a few hours at a time
  • History of self-harm and suicidal behaviour
  • Wrist cutting (attention seeking)
  • Chronic feelings of emptiness
  • Penchant for feeling abandoned
  • Excessive activity to avoid abandonment
  • Paranoia of abandonment
  • Disturbed or unstable self-identity
  • Splitting (defence mechanism): Patients resort to splitting as a defence mechanism; where they see things as being “Black and White” (Good or Bad etc.)
  • May experience dissociative symptoms or paranoid ideas when stressed
• Associated disorders
  • Eating disorder: 62% of women with BPD have been diagnosed with eating disorder
  • Mood disorder: 75% lifetime risk of developing a mood disorder
• Differentials
  • Any mood disorder, especially MDD – is much less insidious, at least 5 SIGECAPS for MDD, Sleep disturbances are more in MDD than isolated BPD. Look for the duration of symptoms
• Psychotherapy for Boderline PD
  • Dialectical-Behavioral Therapy (at type of CBT)
  • Cognitive Behavioral Therapy
  • Interpersonal Pyschotherapy (IPT)
  • Cognitive Analytic Therapy (CAT)
  • Psychodynamic psychotherapy
  • Transference-Focused Pyschotherapy (TFP)
  • Mentalisation-Based Therapy (MBT)
  • Emotion Regulation Training (ERT)
  • Schema-Focused Therapy (SFT)
  • Therapeutic communities (formerly opperational in the United Kingdom but use has declined)
  • Keep a keen eye on mood disorders
• Pharmacotherapy for Boderline PD
  • Antidepressants (usually SSRIs)
  • Antipsychotics (usually low-dose atypicals)
  • Mood stabilisers e.g. valproate, carbamazepine, lithium
  • Others: clonidine, omega-3 fatty acids

Histrionic Personality Disorder

Patient with Histrionic PD are attention-seekers. So-called “Drama-Queen”. More common in women. Associated with somatization and Alcohol use disorder.

F > M

• Features
  • Seductive
  • Inappropriate dress
  • Ego-centric
  • Theatrical behaviour
  • Considers relationships to be closer than they actually are
  • Don’t get along with same sex (have to be the centre of attraction)
  • Language is expretionalistic but lacks details
• Associated conditions
  • Somatic Symptom and Related Disorder
• Differentials
  • BPD – mood symptoms are more prevalent in BPD
  • Delusional disorder, erotomanic type – beliefs are more far-fetched, delusional in nature (Rashida Jones is in love with me). However, in Histrionic PD it is a misinterpretation.
• Treatment
  • SSRI
  • Psychotherapy (Relaxation therapy, exposure therapy, CBT)

Narcissistic Personality Disorder

Patients with Narcissstic PD have an exaggerated opinion of self. Narcissism is named after Narcissus, a hunter in Greek mythology who fell in love with his own reflection in a pool of water.

More common in men. Tend to be in occupations like law and politics. Have a deep-seated fragile self-esteem and are prone to depression. Narcissism is thought to be a defence mechanism that has enveloped their personality for having a low-self-esteem. It is very easy to dislike these patients, caution should be taken to avoid counter-transference. Very easy to dislike these patients

Narcisstic injury and Narcissistic rage

Term	Definition
Narcissistic injury	When a patient with Narcissistic PD gets insulted they get hurt. This may develop into rage.
Narcissistic rage	When a patient with Narcissistic PD gets insulted they may go into a rage where they get physically aggressive or destroy property (may violate the rights of others as in antisocial PD)

• Features
  • Preoccupation with dreams of self-success
  • Grandiose sense of self-importance
  • Very negative reaction to criticism
  • Perfectionism
  • Selfishness
  • Belief that one should only associate with similar high-status people
  • Lack of empathy (inability to identify with the feelings of others)
  • Envy of others
  • Arrogant or haughty attitude
  • Atttention-seeking behavior
  • Sets one’s goals based on gaining approaval from others
• Differentials
  • Bipolar I Disorder or Manic episode – Grandiosity is shorter-lived lived and other mania symptoms are more prominent (impulsivity, flight of ideas, agitations). Narcissistic PD may have delusions of grandeur but that’s just it.
  • Obsessive Compulsive PD: OCPD fixate on perfectionism for its own sake, whereas Narcissistic PD fixate on perfectionism to demonstrate superiority
  • Antisocial Personality Disorder: More extensive history of physical confrontation, flagrantly violating the rights of others
• Treatment
  • Insight-oriented psychotherapy

Avoidant Personality Disorder

Patients with Avoidant PD have a lot of self-criticism and are overly self-conscious. High comorbidity with GAD and OCD

• Features
  • Overly fearful of rejection
  • Avoids social interactions (for fear of criticism or rejection)
  • Low self-esteem
  • Social anxiety
  • Feelings of inferiority
  • Views self as socially inept (thus avoids social situations)
• Differentials
  • Social anxiety disorder: Fear of social interaction central to SAD. Avoidant PD avoid social situations because of feelings of ineptitude/inferiority and less because of embarrassment
  • Generalized anxiety disorder: GAD has no feelings of inferiority or ineptitude. Patient that has been anxious about things in everyday life for > 6 months
  • Paranoid/Schizoid PD: avoidance in paranoid/Schizoid PD is egosyntonic while Avoidant PD is ego dystonic
• Treatment
  • Insight-oriented psychotherapy
  • Group therapy
  • Exposure therapy

Dependent Personality Disorder

Patients with Dependent PD are very dependent on other people. They have low independence due to fear. There is a risk of entering abusive relationships and staying in them (victimization).

• Features
  • Prefers other to make decisions
  • Afraid to be alone
  • Low initiative
  • Hight need of reassurement from others when making decisions
  • Subordination of one’s own needs.
  • Difficulty expressing disagreement (because of fear of losing support)
  • Unwilling to make even reasonable demand of others (but may volunteer to do unreasonable things for others to gain their support)
  • Feels helpless when left alone
• Differentials
  • Avoidant personality disorder – Both have low sense of self. Avoidant PD avoids ppl more in general. Dependent PD cling to certain people for safety and guidance
• Treatment
  • Insight oriented therapy

Obsessive-Compulsive (Anaknastic) Personality Disorder

Patients with Anaknastic PD are RIGID perfectionists. Everything has to be perfect for these patients. They can also hoard and be misers.

• Features
  • Rigid adherence to rules
  • Distressed when working in teams
  • Preoccupied with lists, rules, orders, methods
  • Overconsioencious
  • Overscrupulous
  • Workaholic
  • Excessive focus on detail
  • Miserly
  • Hoarding
  • General attitude of sturbonness
  • Unreasonable insistence that others do things in the same way
• Obsessive Compulsive Disorder vs Obsessive Compulsive Personality Disorder
  • Both have a preoccupation with perfectionism
  • OCD: Egodystonic. The patient complains of intrusive urges. Symptoms may worsen. Motivation is to prevent catastrophe. Seek help for anxiety symptoms.
  • OCPD: Egosyntonic. The patient does not complain of intrusive urges. Symptoms remains the same throughout life. Motivation is to be perfect. Seek help for conflicts in life.
• Differentials
  • OCD: Will be egodystonic, with separate obsessions and compulsions
  • Narcissistic PD: Both have a preoccupation with perfection but narcissists want perfection to reinforce self-importance. OCPD is perfect for perfection’s sake.
• Treatment
  • Insight-oriented therapy

Passive-Aggressive Personality Disorder

• Features
  • Sulkiness/irritability when asked to do something that one does not want
  • Deliberate underperformance in such taks
  • Procrastination
  • Failing to do one’s share of team work
  • Avoids obligation by claiming to have forgotten
  • Protests that others make unreasonable demand
  • Disdain for people in authority