Personality Disorders

Table Of Contents
  1. General Principles
  2. Cluster A
  3. Cluster B
  4. Cluster C

General Principles

Less of a disorder, and more of an enduring set of behavioural traits. Do not just present in the clinic. People with personality disorders don’t see the problem in themselves. 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.

Difficult to treat. May predispose the patient to comorbid psychiatric disorders. CBT and insight-oriented individual psychotherapy are always the treatment of choice

  • Ego Syntonia vs Ego Dystonia
    • Ego Syntonia: Pt is unaware that their behaviour is problematic
    • Ego Dystonia: Pt is aware that their behaviour is problematic
  • Sources of information regarding a patient’s personality
    • Personal history
    • Patient’s opinion of his/ her own personality
      • Give an account of their own personality
      • predict what others would say of him/ her
    • Family and friends’ opinions
    • The interview situation: observation by the clinician
  • Cluster A Personality Disorders (Odd/Eccentric)
    • Paranoid PD
    • Schizoid PD
    • Schizotypal PD
  • Cluster B Personality Disorders (Dramatic/Emotional/Erratic)
    • Antisocial PD
    • Boderline PD
    • Histrionic PD
    • Narcissistic PD
  • Cluster C Personality Disorders (Fearful/Tearful/Neurotic)
    • Avoidant PD
    • Dependent PD
    • Obsessive Convulsive Personality Disorders
  • Investigations
    • Biological
    • EEG: abnormal waves in antisocial and boderline
    • Platelet MAO
    • Hormone levels
    • Psychometric tests
      • Objective (pen and paper)
        • Minnesota Multiphasic Personality Inventory (MMPI 1 & 2)
        • 16 Personality Factor Questionnaire (16PFQ)
        • 5 Personality Factor Questionnaire (5PFQ)
      • Projective (given a stimulus, no wrong or right answer)
        • Make a picture test
        • Rorschach test (ink blot)
        • TAT (Thematic apperception test)
        • Sentence completion
  • Objective vs Projective tests
    • Objective tests (eg. MMPI) are better for testing personality disorders
    • Projective tests (eg. the Rorsharch test) are better for schizophrenia

Cluster A

Predisposed to schizophrenia and psychotic spectrum. Severity worsens from paranoid > Schizoid > schizotypal

Paranoid Personality Disorder

The patient has 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 augmentative
  • Increased risk of MDD
    • Small network of support because of difficulty forming friends
  • Episodes of psychosis
    • Seen with severe stress and psychologically traumatic events. Treat with antipsychotics
  • Differentials
    • Delusional disorder, persecutory type – DD centers around a specific delusion; Paranoid PD delusions is generalized (spans their entire life, friends, work etc.)
    • Schizophrenia – psychotic and/or disorganized thinking
  • Treatment
    • Insight oriented individual psychotherapy
    • Tx psychotic episodes with antipsychotics

Schizoid Personality Disorder

Patient is a loner. Has pseudo psychotic sx (illusions, overvalued ideas, ideas of reference). Finds discomfort in social interactions. Less common and patients tend not to present. Eventually leads 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 (Have features of a “Mganga”)
  • 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

The patient has odd thoughts. Differentiate this from the patient’s cultural/religious ideals.

  • Features
    • Odd behaviour
    • Odd appearance
    • Magical thinking
    • Superstitious
    • Social anxiety/isolation (because they fear people)
  • Though process and content?
    • Coherent.
    • But may be boderline bizzare/delusional.
    • Odd thoughts make them fearful of people
  • Psychotic symptoms
    • During stress or psychologically traumatic events
  • “Schizophrenia spectrum”
    • Think of schizotypal PD in a spectrum with schizophrenia, but these patients have no difficulty functioning in their daily lives
    • 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

Cluster B

Prone to develop mood disorders.

Antisocial Personality Disorder

The patient has no regard for the rights of others. Psychopath (“Anti-society”). Most likely has a criminal record and an Hx of conduct disorder. 18+ for diagnosis. Symptoms soften with age – May be related to testosterone levels.

  • Features
    • Low tolerance for frustration (repeated physical confrontations)
    • Blaming
    • Low capacity for guilt
    • Lacks remorse (May rationalize why they did it)
  • Conduct Disorder
    • The pediatric “equivalent” to Antisocial PD
  • Differentials
    • Intermittent explosive disorder – physical confrontations are isolated and appear once in a while. Intermittent, not pervasive
    • Conduct disorder – patient under 18
    • 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

The patient is emotionally unstable. 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. If the patient qualifies for MDD diagnosed with MDD.

  • Features
    • Impulsivity (Can manifest in many ways and is episodic)
    • Difficult interpersonal relationship (May become more secure with transitional objects – pets, toys)
    • Hx of self-harm and suicidal behaviour
    • Wrist cutting (Seeks attention)
    • Chronic feelings of emptiness
    • Penchant for feeling abandoned
    • Excessive activity to avoid abandonment
    • Paranoia of abandonment
  • Splitting
    • Patients resort to splitting as a defence mechanism; where they see things as being “Black and White” (Good or Bad etc.)
  • Eating disorder
    • 62% of women with BPD have been diagnosed with eating 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
  • Treatment
    • Insight-oriented psychotherapy
    • Keep a keen eye on mood disorders

Histrionic Personality Disorder

The patient is an attention-seeker. “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
  • 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

The patient has an exaggerated opinion of self. More common in men. Occupations like law and politics. Have a deep-seeded fragile self-esteem. Prone to depression.

  • Features
    • Preoccupation with dreams of self-success
    • Very negative reaction to criticism
    • Perfectionism
    • Selfishness
  • Deep-seated fragile self-esteem
    • Narcissism is a defence mechanism that has enveloped their personality for having low self-esteem
    • Avoid counter-transference. Very easy to dislike these patients
  • “Narcissistic injury” and “Narcissistic rage
    • Narcissistic injury: insult patient with Narcissistic PD. Gets hurt. May develop rage.
    • Narcissistic rage: Insult patient. Goes into a rage where they may beat you up or destroy property (violates rights of others as in antisocial PD)
  • 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

Cluster C

Prone to develop anxiety disorders and related.

Avoidant Personality Disorder

The patient has a lot of self-criticism and is overly self-conscious. High comorbidity with GAD and OCD

  • Features
    • Overly fearful of rejection
    • Avoids social interactions
    • 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. Pt 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

The patient is very dependent on other people. Has low independence due to fear. 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 reasurement from others when making decisions
    • Subordination of one’s own needs.
  • 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 Personality Disorder

The patient is a RIGID perfectionist. Everything has to be perfect for these patients. Also hoarders and misers.

  • Features
    • Rigid adherence to rulses
    • Distressed when working in teams
    • Preoccupied with lists, rules, orders, methods
    • Overconsioencious
    • Overscrupulous
    • Workaholic
    • Excessive focus on detail
    • Miserly
    • Hoarding
  • Obsessive Compulsive Disorder vs Obsessive Compulsive Personality Disorder
    • Both have a preoccupation with perfectionism
    • OCD: Egodystonic. Pt complains of intrusive urges. Sx worsen. Motivation is to prevent catastrophe. Seek help for anxiety sx.
    • OCPD: Egosyntonic. Pt does not complain of intrusive urges. Sx 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