Personality Disorders

Personality

Personality Style: lifelong way of coping,

manifested in how a person thinks, feels and

behaves

Personality

Stable and predictable

Flexible and adaptive

“ We continue to shape our personality all our life . If we knew ourselves perfectly , we should die “

Albert Camus

Personality Style vs Disorder

Matter of degree

Style is stable but can be modified

Disorder

rigid

extreme

maladaptive

damaging to self or others

leading to functional impairment

History of long-term difficulties

Ego-syntonic

Lack of empathy

Developmental fixation

Immaturity

Anxiety underneath the protective armor

Epidemiology

Prevalence : 9.1% for any PD (DSM V)

First evident in late adolescence / early

adulthood

Etiology

Multifactorial

Genetics

Perinatal injury , encephalitis , head trauma

History of family dysfunction, abuse

Course and Prognosis

Usually stable or deteriorating but

some patients do improve over time.

“Everyone is a moon, and has a dark side which he

never shows to anybody “

Mark Twain

PERSONALITY

DISORDERS

CLUSTER A

PARANOID

SCHIZOID

SCHIZOTYPAL

CLUSTER B

ANTISOCIAL

BORDERLINE

NARCISSISTIC

HISTRIONIC

CLUSTER C

OBSESSIVE-COMP

AVOIDANT

DEPENDENT

Paranoid P D

Tendency to attribute malevolent

motives to others

Persistently bears grudges

Jealous, Secretive

Genetic component

Defenses: projection , denial ,

rationalization

Schizoid P D

Isolated life style without overt longing

for others

Lack of interest in sexual experiences

Men > women

Genetic factors, family dysfunction

Diff dx: Autism

Schizotypal P D

Odd & eccentric

Magical thinking

No close relationships

Social anxiety

Paranoia

Precursor to schizophrenia

Men > women

Antisocial P D

Disregard and violation of the rights of

others

Familial pattern

Hx of parental abandonment , abuse

Conduct disorder prior to age 15

Death by violence , SA , suicide

Lack of remorse

Borderline PD

Instability, Impulsivity

Splitting

Primitive idealization

Projective identification

Fear of abandonment

Self-hate

Emptiness , object hunger

Dissociation

Borderline PD

Need for transitional object

Women > Men

Frequent hx of physical , sexual abuse

Transference psychosis

Suicide threats, self-mutilation

Co-occuring: affective disorders

,substance use, eating disorders, PTSD

Histrionic P D

Dramatic , emotional style

Seductive

Center of attention

Shallow affect

Women > Men

Co-occuring with Somatization ,

Conversion Disorder

Narcissistic P D

Grandiosity , sense of entitlement

Lack of empathy

Feels special

Envy , manipulation

Compensation for sense of inferiority

Early rejection , loss

Obsessive-Compulsive P D

Perfectionism , inflexibility

Miserly spending style

Excessive devotion to work

Preoccupation with details

Fixation during anal period

Men > Women

Avoidant P D

Shy , timid personality

Fear of rejection

Feels inferior to others

Fear of negative evaluation

Co-occuring with Social Phobia

Risk-aversion

Desire for companionship

Dependent P D

Predominantly dependent and

submissive

Fear of separation

Lack of self-confidence

Difficulty making independent

decisions

Women > men

Unresolved separation issues

Diagnostic Tools

Minnesota Multiphasic Personality Inventory

(MMPI)

Structured Clinical Interview for

DSM for Axis II Disorders (SCID-II and soon

SCID-5-PD)

Reactions to the Patient

Countertransference

Intense feelings

Fantasies

Atypical Behaviors

“There is nothing so dangerous for anyone who has

something to hide as conversation.

A human being, Hastings, cannot resist the opportunity

to reveal himself and express his personality, which

conversation gives him.

Every time, he will give himself away.”

Agatha Christie: Hercule Poirot

Management

Learn to listen

Stabilize the external environment

Stabilize the internal environment: medications

Set limits

Accept the patient`s limitations

Question irrational beliefs

Enlist family support

Pharmacotherapy Options

SSRIs

Low-dose atypical antipsychotics

Lithium and anticonvulsant mood stabilizers

Benzodiazepines should be avoided, if possible

Treatment

Psychotherapy

Dialectical Behavioral Therapy

Cognitive Therapies

Psychodynamic Therapies

Remember to

Pay attention to your own emotional

reaction to the patient

Use consultation , referral and support

Maintain good boundaries

Treat patients with patience and empathy

“ Men acquire a particular quality by constantly acting a particular way. You become just by performing just actions, temperate by performing temperate actions, brave by performing brave actions.”

Aristotle