Week 12: Personality Disorders

What are personality disorders?

Adult personality is the accumulation of early childhood experiences. During various stages, children learn to solve emotional problems. Defense mechanisms are aimed at decreasing anxiety and are organized within the ego. So, the term personality implies the manner in which a person interacts with their environment and other people. A personality disorder characterizes those individuals who usually respond poorly to changes & exhibit deficiencies in their capacity to form relationships - inflexible in their schema. Problems occur when traits, or those features that make up a personality remain inflexible, thus impairing the person’s ability to interact with their social environment and with others. Often these disorders result from childhood trauma and they don’t develop the higher order defense mechnisms.

What balances an individual’s internal drives and external world?

An indivdualized repertoire of defense mechanisms. A person’s personality can be defined as those emotional and behavioral traits that characterize day-to-day living under normative conditions. This repertoire is seen as “personality;” a set of characteristics defining the behaviors, thoughts, and emotions of each individual. These characteristics become so ingrained that they usually dictate the person’s worldview. An individual’s personality becomes relatively predictable. When the traits are extremely inflexible and maladaptive and cause significant functional impairment or subjective distress, that constitute a personality disorder. Deeply ingrained, inflexible, rigid, problematic, and maladaptive patterns of relating to others and in self-perception.

How does The DSM-5 define a personality disorder?

“an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive, and inflexible, and has an onset in adolescence or early adulthood is stable over time, and leads to distress or impairment.”

How do we categorize personality disorders?

The DSM-1 (otherwise known simply as the DSM) described 27 “personality disorders” and organized them into 5 specific headings: 1. Personality pattern disturbance. 2. Personality trait disturbance. 3. Sociopathic personality disturbance. 4. Special symptom reactions. 5. Transient situational personality disorders. The DSM-II eliminated the subheadings and reduced the number from 27 to 12. The DSM-III developed the Axis II The DSM-III-R described 11 personality disorders and subdivided them into three “clusters.”

What are characteristics of personality disorders?

Long-term, stable patterns or unusual and inflexible personality characteristics leading to pervasive impairment or interpersonal distress throughout a person’s life. We would see impairment in two (or more) of the following: Cognition: Ways of perceiving and interpreting oneself, other people, and events. Affectivity: The range, intensity, and appropriateness of emotional response(s). Interpersonal functioning: The instability of and inability to maintain relationships; poor self-image or self-esteem. Impulse control: The ability to withhold inappropriate verbal or motor responses while completing a task; speaking or acting without anticipating the repercussions of their behavior.

What are people with PD like?

Aren’t able to adapt their behavior to various situations. Exhibit traits so out of proportion or inflexible that they often cause problems for themselves and for those around them. Almost always exhibit the following: Inflexible across a wide range of interpersonal and intrapersonal situations. An enduring pattern of behavior leading to significant distress or impairment. Behaviors that are stable and of long duration with onset usually traced back to at least adolescence or early adulthood. Behavior that is not better explained by another mental disorder. Behavior that is not due to the direct physiological effects of a substance or a general medical condition. They are more in touch with reality.

What is cluster A?

Odd, eccentric - paranoid, schizoid, schizotypal. These individuals appear odd and eccentric. The disorders are often associated with schizophrenia

What does a person with Schizotypal PD show?

cognitive or perceptual distortions and eccentricities of behavior and often very uncomfortable in close relationships.

What does a person with Paranoid PD show?

They can be paranoid in contrast to someone with Schizoid PD who might have difficulty being understood by others since they have an odd or eccentric manner and lack close relationships. But, they tend to have a greater grasp on reality in contract with people with schizophrenia.

What is the behavior in paranoid PD?

The behavior is characterized by pervasive, groundless suspiciousness and an inherent distrust of others. The person may be described as hostile, irritable, angry, refuses to take responsibility for his/her own actions and feelings. They generally interpret innocent remarks as insults, threats, or some form of malevolence. They do not generally confide in or trust others.

What is Paranoid PD criteria?

We would see 4 or more of the following: Suspicion: Without having any evidence, the person tends to be preoccupied assuming others are some how betraying or being unfaithful to them. Unjustified doubts: Preoccupied about loyalty or trustworthiness of friends or others. Problems with intimacy: Difficulty confiding in others, distrusting and afraid the information will be used against them. Hidden meanings: A casual remark seen as a direct attack. Holding grudges: Unable to forgive slight insults. Paranoia: Minor slight raises major hostility that last for a long time. Recurrent suspicions: Strong tendency to have doubts, or misgivings. Constantly questions others’ fidelity.

What are Paranoid PD Prevailing patterns?

Prevalence is about 1 in 10 adults in the US or 2.3% to 4.4% of the general population. More commonly diagnosed in men than in women. There does not seem to be a familial patterns. Rarely seeks help. It’s tought to form a therapeutic bond with them.

What is Paranoid PD Differential assessment?

The personality can be described as Chronically sarcastic, argumentative, angry, irritable, and querulous. “Chip on their shoulder.” Relationships with others can be described as tense. A barking dog is the neighbor’s deliberate attempt to be annoying. A profound negative, bitter, and cynical attitude. The individual is cold and humorless, extremely self-protective of their own interests, jealous,controlling, and possessive.

What would we see in paranoid PD?

We would see paranoia. They typically want relationships with others. In Borderline PD and Histrionic PD we would not see suspiciousness. In Avoidant PD the person fears being embarrassed or seen as inadequate rather than suspecting malicious intent as seen in paranoid PD. Those with schizotypal traits are set apart by symptoms of magical thinking, odd speech but not paranoia.

What is Schizoid Personality Disorder?

We would see a lifelong pattern of - Social withdrawal, Introverted and isolated from others by choice, Bland and solitary lifestyles, Very little human interaction, Eccentric and lonely and ill at ease in others’ company. There is no disordered thinking that is apparent in those with schizophrenia, bipolar disorder, or depressive disorder with psychotic features, or autism. The individual’s childhood may reveal a history of having been a loner.

What is the Schizoid PD Prevailing pattern?

The least commonly diagnosed disorder.

There may be a role of biological influences in combination with family socialization and early learning or relationship problems. Onset typically occurs during early childhood and prevalence is estimated to be at 4.9%.

What is the Schizoid PD Differential assess?

These individuals lead quiet, distant, reclusive, and unsociable lives with very little need or desire for emotional ties. They tend to daydream excessively and/or become attached to animals.

What are the criteria in scizoid PD?

We would see 4 or more of the following: (No penchant for social relationships, Preference for solitary activities, Little or no sex drive, Takes pleasure in few, if any, activities, Lacks close friends other than first-degree relatives., Acts indifferently to praise (or criticism) of others, Limited range of emotions).

How is schizoid PD distinguished from other PDs?

Distinguished from schizotypal by the lack of cognitive and perceptual distortions. Paranoid PD people are most socially connected and have a greater tendency to project their feelings onto others. Avoidant PD also characterized by isolation, but they show a strong desire to participate in activities, while this disorder wants to be alone.

What is Schizotypal PD?

We would see strikingly odd or strange mannerisms in addition to having a very active fantasy life. We would also see “magical thinking:” an irrational belief that one has powers that defy laws of nature and physics and thus can cause or prevent events,

What do we need to see in schizotypal PD?

We need to see 5 or more of the following: Ideas of reference, Odd beliefs, Unusual perceptual experiences, Odd thinking or speech, Suspiciousness or paranoid ideation, Inappropriate or constricted affect, Behavior or appears that is odd, eccentric, or peculiar, Lack of friends, Anxiety in social situations.

What is Schizotypal PD Prevailing pattern?

Approximately 4.6% of the population in the US. Explore the family history for evidence of schizophrenia. Most similar to schizophrenia of all the PDs. Typically beginning in early adulthood.

What is the Schizotypal PD Differential assessment?

Associated with schizophrenia. But no hallucinations or delusions. People with this PD experience subtle distortions of their environment. We would NOT see psychosis but may see anhedonia, and some depression. Oddities in behavior, thinking, perception, and communication distinguish those individuals with schizophrenia from those with other types of personality disorders.

How does schizotypal differ from other PDs?

Both paranoid and schizoid PDs are characterized by social detachment and restricted affect, but Schizotypal has the cognitive (or perceptual) distortions and marked eccentricity or oddness. People with narcissistic PD also are uncomfortable if they have to talk to people but the narcissist PD individual is more afraid of having their flaws or imperfections revealed.

What is cluster B?

Emotional, dramatic, or erratic - antisocial, borderline, histrionic, narcissistic. People with a diagnosis in this cluster share problems with impulse control and emotional regulation.

What does ntisocial PD show?

a contemptuous disregard of others.

What does Borderline PD show?

a marked instability and roller coaster of emotions.

What does Histrionic PD revolve around?

attention-seeking, but they are usually confined to sexual conquests and the persons irresistibility to seduce others.

What does Narcissistic PD have?

behavior is organized around a person's sense of fantastic grandiosity, brilliance, perfection, and power.

What is Antisocial PD?

We would also see theft, lying, substance abuse, rejection of social norms asocial or criminal acts. Begins in childhood and intensifies during adolescence Look to see if the person had conduct disorder as a child.

What are the criteria for antisocial PD?

Three or more of the following: Defiance of or failure to conform to social norms, Deceitful or the absence of consistent truthfulness, Impulsive, Irritable and aggressive, Reckless disregard for the safety or self or others, Irresponsible, Lack of remorse or empathy.

What is Antisocial PD Prevailing pattern?

The 12-month prevalence rates are between 0.2% and 3.3% of the population. Much more prevalent in men. Increased risk for substance abuse, alcoholism, vagrancy, suicide, criminal activity, repeated incarceration, death by violence. Usually lifelong and chronic. As the person reaches age 30, many burn out and gradually their antisocial acts decrease. They lost their energy

What is the Antisocial PD Differential Assessment?

The problem behaviors usually begin after the age of 15. They may have been the neighborhood bully. Often cruel toward animals. Stealing from friends, being irresponsible. Appear out of control. They remain unmoved by any kindness shown, steal and destroy property for the pleasure of it, and habitually lie even when telling the truth. More common in first-degree relatives. They may present themselves as fascinating, disarming, and beguiling – con artists.

What is Borderline PD?

One of the most common PDs. An unstable mood, extremely poor and chaotic relationships with others, low self-image alternating between extremes of idealization and devaluation. Very intense, often going from strong feelings of anger to depression in a very short period of time. Many engage in self-injurious behaviors. The person often complains of feeling empty, chronically bored, difficulty with their own identity. The person loves you and then hates you.

What are Borderline PD Symptoms?

Five or more must be present: Frantic efforts to avoid abandonment, Poor interpersonal relationships, Identity disturbance or unstable self-image, Marked impulsivity, Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior, Affective instability, Chronic feelings of emptiness, Inappropriate, intense anger, Transient stress-related paranoid ideation or severe dissociative symptoms.

What is Borderline PD Prevailing pattern?

Pervasive pattern of unstable relationships, Frantic efforts to avoid real or imagined abandonment, Alternating between extremes of idealization and devaluation, Identity disturbance, Engaging in recurrent suicidal behavior., Markedly impulsive behaviors such as spending money, sexual encounters, and substance use, Symptoms tend to lessen as the person ages.

What is Borderline PD Differential Assessment?

Histrionic PD: Shows extreme emotions but not chronic feelings of emptiness or loneliness, or self-destructive behaviors. Schizotypal PD may have paranoid ideas but in borderline, the symptoms are more transient, interpersonally reactive, and responsible to external structuring.Narcissistic PD: We would not see the self-destructive behaviors. Dependent PD: Has abandonment concerns, but the person tends to be more appeasing.

What is Histrionic PD?

The person with this PD has a far greater problem relating to others. The person may be described as colorful, dramatic, extroverted, excitable, and emotional. Underneath, there is a deep-seated inability to maintain strong, reciprocal, and long-lasting friendships. These individuals attempt to acquire attention in inexplicable ways. We would see extreme attention seeking and highly expressive emotions. They tend to incessantly involve others in their life drama. Others frequently describe them as superficial, disingenuous, and unconvincing.

What is the Histrionic PD Symptomatic picture?

Five or more of the following: Grandiose sense of self-importance, Preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. Show rapidly shifting and shallow expression of emotions, Concerns with ‘presentation’ or physical appearance, Speech that is excessively impressionistic and lacks detail – more dramatic speech with rapid shifts of emotion. Easily influenced and susceptible. Considers relationships more intimate than they actually are.

What is Histrionic PD Prevailing pattern?

The prevalence is 1.84% of the general population. This is a lifelong pattern of behavior, although symptoms generally tend to diminish by aging. The disorders originate in childhood. They usually get into trouble with the law, substances, and promiscuity.

What is the Histrionic PD Differential Assessment?

Excessive emotionality and attention seeking, which seeps into most areas of their lives. Very provocative and sexually seductive. Always overly concerned with their physical attractiveness. Relationships are typically stormy and short-lived, the person becomes easily bored with others. They are often described as shallow, lacking in substance, and incapable of having reciprocal meaningful relationships.

How does histrionic disorder differ from other PDs?

Narcissistic PD: May be self-aggrandizing, but they lack the intense emotion. Borderline PD: May be flamboyant and self-destructive; however, they have an enduring sense of emptiness and loneliness. People with this pd are seen as shallow and lacking in substance. Antisocial PD: Highly impulsive however, people with this pd become dependent on, or deeply attached to, others.

What is Narcissistic PD?

A heightened sense of self-importance and unrealistic inflated self-worth often disguising an underlying fragile sense of self. They think exceedingly highly of themselves and have an intense need for admiration and truly believe they are unique and special.

What are the criteria for narcissistic PD?

They must show five or more: Grandiose sense of self-importance, Preoccupied with fantasies of success, Belief in being special and unique, Constant desire or need for admiration, Sense of entitlement, Interpersonally exploitative, Lacks empathy, Envious of others or believes that others are envious of them, Shows arrogant, haughty behaviors/attitudes.

What is the Narcissistic PD Prevailing Pattern?

The disorder occurs in less than 1% of the general population. More often in males than females (go the histrionic route). The disorder is chronic and difficult to treat. We would see bouts of depression, very poor ability to handles the aging process, more vulnerable to midlife crises.

What is the Narcissistic PD Differential Assessment?

The disorder often coexists with antisocial, histrionic, and borderline personality disorders. Antisocial PD: In addition to being arrogant, they almost always exploit others for financial power or material gain. Histrionic PD: Tend to be self-absorbed and eager to be the center of attention, but they are usually more willing to connect with others. Schizotypal and Paranoid PD: Tend to show more signs of suspiciousness and social withdrawal. Obsessive-compulsive PD: Tend to be much more self-critical.

What is cluster C?

Anxious, fearful - Avoidant, dependent, obsessive-compulsive. This cluster includes avoidant, dependent, and obsessive-compulsive personality disorders.

What would we see in Avoidant PD?

We see much fear of ridicule, rejection, or criticism.

What would we see in dependent PD?

People may show a need to be taken care of, fear of losing the support of others and often leads to very clingy behavior. Some people submit to the desires of others and frequently at their own expense.

What would we see Obsessive-Compulsive PD?

There may also be much preoccupation with control and a lack of flexibility, openness, and efficiency.

What is avoidant PD?

Pervasive and generalized timidity, social inhibition, avoidance, and extreme sensitivity to negative remarks. Desire for acceptance and low self-esteem. Fear of being embarrassed or saying something inappropriate.

What are the criteria for avoidant PD?

Four or more of the following: Avoids occupational activities involving significant interpersonal contact. Unwilling to get involved with others unless they can be certain they will be liked. Shows restraint within intimate relationships. Preoccupied with being criticized or rejected. Inhibited in new interpersonal situations. Consider themselves as socially inept, personally unappealing, or inferior to others. Reluctant to take personal risks or to engage in any new activities.

What is the Avoidant PD prevailing pattern?

Prevalence is about 2.4% in the general population. Seems to occur equally in males and females.

What is Avoidant PD Differential assessment?

These people are very inhibited and overly cautions. They fear new situations will throw them a curve for which they aren’t prepared. They have a propensity to be self-effacing and eager to please. These qualities often lead to marked social detachment. We would see feelings of low self-esteem, being standoffish or introverted, fear of closeness to and rejection by others, social awkwardness, and chronic fear of being embarrassed. They have a chronic, lifelong pattern of social withdrawal grounded in the anticipation of being rejected. They would like to have a relationship with others, but they are extremely sensitive to any form of criticism.

How does avoidant PD differ from other PDs?

Schizoid PD and Schizotypal PD: Desire to spend most of their time alone and isolated, but in avoidant PD, the person wants to have social contact, but is just fearful of it. Dependent PD: Wants interpersonal relationships, but becomes overly dependent on others to make decisions for them. Paranoid PD: The person believes others have malicious intent. Social Phobias: The person has problems with specific situations (such as speaking in public), people with avoidant PD have issues in personal relationships.

What is Dependent PD?

A pervasive pattern of extreme inability to act independently of others. They may allow others to take responsibility for their lives and to make decisions for them. They feel helpless when alone; subjugate their needs to those of others; endure mistreatment in order to maintain a relationship; and are unable to function when self-assertiveness is required. They will often tolerate almost any kind of behavior on the part of others who seem to meet their needs. They go to great lengths to avoid undertaking or assuming positions of responsibility. They prefer to perform tasks under someone else’s direction - even getting dressed. They have excessive demands for reassurance eventually becoming so bothersome and irritating that most people are driven away.

What are the dependent PD criteria?

We would see 5 or more of the following: Difficulty making everyday decisions, Need for others to assume responsibility for most major areas of their life, Difficulty expressing disagreement, Difficulty initiating projects or doing things independently, Goes to extreme lengths to obtain nurturance and support, Feels uncomfortable when alone, When a close relationship has ended, seeks another relationship for support, Preoccupied with fears of being left alone to care for self.

What is the Dependent PD: Differential assessment?

Histrionic and Borderline PD: There may be dependency needs, but these individuals usually can’t maintain relationships with anyone in particular. Avoidant PD: May fear being humiliated by the dependent PD is distinguished by submissive, reactive, and clinging behaviors.

What is Obsessive-Compulsive PD?

These individuals do not have obsessions or compulsions in the same sense that they do in OCD. Rather, the energy of the person’s entire personality is channeled into “perfectionism.” These individuals are rigid, orderly, inflexible, and emotionally constricted. They often have difficulties making decisions and appear excessively moralistic and have trouble completing tasks. They are characterized as headstrong and preoccupied with doing things the right way.

What are the OCPD criteria?

We would see four or more of the following: Preoccupied with details, rules, lists, order, organization, or schedules. Perfectionism. Excessively devoted to work and productivity. Over conscientious, scrupulous, inflexible about matters of morality, ethics, or values. Difficulty discarding worthless objects. Difficulty delegating tasks or to work with others. Miserly or stingy toward self and/or others. Shows rigidity or stubbornness. They often have difficulty finishing tasks because they’re so obsessed with the details.

What is the Obsessive-Compulsive PD Prevailing pattern?

The prevalence ranges from 2.1% to 7.9%. They are more apt to seek intervention on their own than are people with other personality disorders. Often have stable relationships and marriages but usually have few close friends, and their lives tend to be constricted and joyless.

What is the Obsessive-Compulsive PD Differential Assessment?

OCD is distinguished by thinking obsessions and performing compulsions. Individuals with OC PD tend to become lost in details and are completely immobilized by indecision. Individuals appear to be supersaturated with upholding the highest level of scruples and are inflexible regarding moral and ethical matters. The are often seen as cold, insensitive, single-minded, stubbornly rigid, frugal, parsimonious, and miserly.

How does OCPD differ from other PDs?

Narcissistic PD: Although they are concerned with perfection and correctness, they are focused on seeking adulation. Antisocial PD: Tend to lack generosity but can be seen to indulge themselves, in contrast to the person with OC PD who adopts what could be characterized as miserliness. Schizoid PD: Can be seen in formality and social detachment, whereas these features come from a place of discomfort with emotions and excessive devotion to work as seen in this.

What are other PDs?

Personality d/o due to another medical condition, other-specified PD, unspecified PD