Personality disorders | Anatomy2Medicine
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Personality disorders

 

  • Personality disorders

 

      • People with personality disorders deny their problems and refuse psychiatric help

 

  • Personality disorder symptoms are alloplastic

 

      • Alloplastic can adapt to, and alter, the external environment.
      • Symptoms are ego-syntonic i.e. acceptable to the ego
      • People with personality disorders do not feel anxiety about their maladaptive behaviour.

 

  • Personality disorders

 

      • Cluster-A Personality Disorders include:
        • Paranoid
        • Schizoid
        • Schizotypal

 

  • Cluster-B personality disorders

 

        • Antisocial
        • Borderline
        • Histrionic
      • Cluster-C Personality Disorders include:
        • Avoidant
        • Dependent
        • Obsessive-Compulsive
        • Not otherwise specified
    • Medical conditions associated with personality change include
      • Acquired Immune Deficiency Syndrome
      • Complex Partial Seizures
      • Mercury Poisoning
      • Neurosyphilis
      • Head trauma
      • Cerebrovascular diseases
      • Cerebral tumours
      • Huntington’s disease
      • Multiple sclerosis
      • Manganese poisoning
      • Dementia
      • Anabolic steroids i.e.Oxymetholone ,Somatropin ,Stanozolol Testosterone, etc.
    • Psychophysiological disorders
      • Bronchial Asthma
      • Colitis
      • Migraine
    • Meyer Friedman and Ray Rosenman defined type-A and  type-B personalities.

 

  • Type A personalities

 

        • strongly associated with development of the coronary heart disease, are action-oriented people who struggle to achieve poorly defined goals of life by means of competitive hostility.

 

  • They are aggressive, impatient, upwardly mobile, striving, and angry when frustated.

 

        • Type A personalities have increased amounts of low-density lipoproteins, serum cholesterol, triglycerides, and 17-hydroxy corticosteroids.
      • Type B personalities are the opposite:
        • relaxed, less aggressive and less concerned with striving vigorously to achieve their goals.

 

  • Commonest psychological manifestation of AIDS is Depression
  • “Paranoid Personality Disorder
  • Suspiciousness
  • Sensitiveness
  • Sense of Importance

 

  • Suggestibility is a feature of “Histrionic” personality disorder, where the affected person gets easily influenced by others or circumstances.

 

    • Personality is one’s set of stable, predictable emotional and behavioral traits.
    • Personality disorders involve deeply ingrained, inflexible patterns of relating to others that are maladaptive and cause significant impairment in social or oc-cupational functioning.
    • Patients with personality disorders lack insight about their problems; their symptoms are ego-syntonic. Personality disorders are Axis II diagnoses.

 

  • DIAGNOSIS AND DSM-IV CRITERIA

 

    • Pattern of behavior/inner experience that deviates from the person’s culture and is manifested in two or more of the following ways:
    • Cognition
    • Affect
    • Personal relations
    • Impulse control

 

  • The pattern:

 

    • Is pervasive and inflexible in a broad range of situations
    • Is stable and has an onset no later than adolescence or early adulthood
    • Leads to significant distress in functioningIs not accounted for by another mental/medical illness or by use of a substance

 

  • Each personality disorder is present in 1% of the population.

 

  • Personality disorders are divided into three clusters:
  • Cluster A—schizoid, schizotypal, and paranoid:
  • Patients seem eccentric, peculiar, or withdrawn.
  • Familial association with psychotic disorders
  • Cluster B—antisocial, borderline, histrionic, and narcissistic:
  • Patients seem emotional, dramatic, or inconsistent.
  • Familial association with mood disorders
  • Cluster C—avoidant, dependent, and obsessive–compulsive:
  • Patients seem anxious or fearful.
  • Familial association with anxiety disorders
  • Personality disorder not otherwise specified (NOS) includes disorders that do not fit into clusters A, B, or C (including passive–aggressive personality disorder).
  • TREATMENT
  • Psychotherapy and group therapy are usually the most helpful.

CLUSTER A

    • Paranoid, schizoid, and schizotypal.
      • These patients are perceived as being eccentric and “weird.”

 

  • Paranoid Personality Disorder (PPD)

 

      • Patients with PPD have a pervasive distrust and suspiciousness of others and often interpret motives as malevolent.

 

  • They tend to blame their own prob- lems on others and seem angry and hostile.
  • DIAGNOSIS AND DSM-IV CRITERIA

 

        • Diagnosis requires a general distrust of others, beginning by early adulthood and present in a variety of contexts.
        • At least four of the following must also be present:

 

  • Suspicion (without evidence) that others are exploiting or deceiving him or her

 

          • Preoccupation with doubts of loyalty or trustworthiness of acquain- tances
          • Reluctance to confide in others
          • Interpretation of benign remarks as threatening or demeaning
          • Persistence of grudges
          • Perception of attacks on his or her character that are not apparent to others; quick to counterattack
          • Recurrence of suspicions regarding fidelity of spouse or lover

 

  • EPIDEMIOLOGY

 

        • Prevalence: 0.5 to 2.5%
        • Men are more likely to have PPD than women.

 

  • Higher incidence in family members of schizophrenics

 

      • DIFFERENTIAL DIAGNOSIS

 

  • Paranoid schizophrenia: Unlike patients with schizophrenia, patients with paranoid personality disorder do not have any fixed delusions and are not frankly psychotic, although they may have transient psychosis under stressful situations.

 

      • COURSE AND PROGNOSIS

 

  • Some patients with PPD may eventually be diagnosed with schizophre- nia.

 

        • The disorder usually has a chronic course, causing lifelong marital and job-related problems.
      • TREATMENT
        • Psychotherapy is the treatment of choice.
        • Patients may also benefit from antianxiety medications or short course of antipsychotics for transient psychosis.

 

  • Schizoid Personality Disorder

 

      • Patients with schizoid personality disorder have a lifelong pattern of social withdrawal.
      • They are often perceived as eccentric and reclusive.
      • They are quiet and unsociable and have a constricted affect.
      • They have no desire for close relationships and prefer to be alone.
      • DIAGNOSIS AND DSM-IV CRITERIA
        • A pattern of voluntary social withdrawal and restricted range of emotional ex- pression, beginning by early adulthood and present in a variety of contexts.
        • Four or more of the following must also be present:
          • Neither enjoying nor desiring close relationships (including family)
          • Generally choosing solitary activities
          • Little (if any) interest in sexual activity with another person
          • Taking pleasure in few activities (if any)
          • Few close friends or confidants (if any)
          • Indifference to praise or criticism
          • Emotional coldness, detachment, or flattened affect
      • EPIDEMIOLOGY
        • Prevalence: Approximately 7%
        • Men are two times as likely to have schizoid personality disorder as
        • women.
        • There is not an increased incidence of schizoid personality disorder in families with history of schizophrenia.
      • DIFFERENTIAL DIAGNOSIS
        • Paranoid schizophrenia: Unlike patients with schizophrenia, patients with schizoid personality disorder do not have any fixed delusions, al- though these may exist transiently in some patients.
        • Schizotypal personality disorder: Patients with schizoid personality disorder do not have the same eccentric behavior or magical thinking seen in patients with schizotypal personality disorder.
      • COURSE : Usually chronic course, but not always lifelong
      • TREATMENT
        • Similar to paranoid personality disorder:
        • Psychotherapy is the treatment of choice
        • Group therapy is often beneficial.
        • Low-dose antipsychotics (short course) if transiently psychotic, or anti-depressants if comorbid major depression is diagnosed

 

  • Schizotypal Personality Disorder

 

      • Patients with schizotypal personality disorder have a pervasive pattern of ec- centric behavior and peculiar thought patterns.

 

  • They are often perceived as strange and eccentric.

 

      • DIAGNOSIS AND DSM-IV CRITERIA
        • A pattern of social deficits marked by eccentric behavior, cognitive or perceptual distortions, and discomfort with close relationships, beginning by early adulthood and present in a variety of contexts.
        • Five or more of the following must be present:
          • Ideas of reference (excluding delusions of reference)
          • Odd beliefs or magical thinking, inconsistent with cultural norms

 

  • Unusual perceptual experiences (such as bodily illusions)

 

          • Suspiciousness

 

  • Inappropriate or restricted affect

 

          • Odd or eccentric appearance or behavior
          • Few close friends or confidants
          • Odd thinking or speech (vague, stereotyped, etc.)
          • Excessive social anxiety
        • Magical thinking may include:
          • Belief in clairvoyance or telepathy
          • Bizarre fantasies or preoccupations
          • Belief in superstitions

 

  • Odd behaviors may include involvement in cults or strange religious practices.

 

      • EPIDEMIOLOGY
        • Prevalence: 3.0%
        • More prevalent in monozygotic than dizygotic twins
      • DIFFERENTIAL DIAGNOSIS
        • Paranoid schizophrenia: Unlike patients with schizophrenia, patients with schizotypal personality disorder are not frankly psychotic (though they can become transiently so under stress).
        • Schizoid personality disorder: Patients with schizoid personality disorder do not have the same eccentric behavior seen in patients with schizo- typal personality disorder.

 

  • COURSE : Course is chronic or patients may eventually develop schizophrenia.

 

    • TREATMENT
      • Psychotherapy is the treatment of choice.
      • Short course of low-dose antipsychotics if necessary (for transient psychosis)

CLUSTER B

    • Includes antisocial, borderline, histrionic, and narcissistic personality disorders.
    • These patients are often emotional, impulsive, and dramatic.

 

  • Antisocial Personality Disorder

 

      • Patients diagnosed with antisocial personality disorder refuse to conform to social norms and lack remorse for their actions.
      • They are impulsive, deceitful, and often violate the law.
      • However, they often appear charming and normal to others who meet them for the first time and do not know their history.
      • DIAGNOSIS AND DSM-IV CRITERIA
        • Pattern of disregard for others and violation of the rights of others since age 15.
        • Patients must be at least 18 years old for this diagnosis; history of behav- ior as a child/adolescent must be consistent with conduct disorder
        • Three or more of the following should be present:
          • Failure to conform to social norms by committing unlawful acts
          • Deceitfulness/repeated lying/manipulating others for personal gain
          • Impulsivity/failure to plan ahead
          • Irritability and aggressiveness/repeated fights or assaults
          • Recklessness and disregard for safety of self or others
          • Irresponsibility/failure to sustain work or honor financial obligations
          • Lack of remorse for actions
      • EPIDEMIOLOGY
        • Prevalence: 3% in men and 1% in women
        • Higher incidence in poor urban areas and in prisoners
        • Genetic component: Five times increased risk among first-degree relatives
      • DIFFERENTIAL DIAGNOSIS
        • Drug abuse: It is necessary to ascertain which came first. Patients who began abusing drugs before their antisocial behavior started may have behavior at- tributable to the effects of their addiction.
      • COURSE
        • Usually has a chronic course, but some improvement of symptoms may occur as the patient ages.
        • Many patients have multiple somatic complaints, and co- existence of substance abuse and/or major depression is common.
      • TREATMENT
        • Psychotherapy is the treatment of choice.
        • Pharmacotherapy may be used to treat symptoms of anxiety or depression, but use caution due to high addictive potential of these patients.

 

  • Borderline Personality Disorder (BPD)

 

    • Patients with BPD have unstable moods, behaviors, and interpersonal rela- tionships.
    • They feel alone in the world and have problems with self-image.
    • They are impulsive and may have a history of repeated suicide attempts/ges- tures or episodes of self-mutilation.
    • DIAGNOSIS AND DSM-IV CRITERIA
      • Pervasive pattern of impulsivity and unstable relationships, affects, self-image, and behaviors, present by early adulthood and in a variety of contexts.
      • At least five of the following must be present:
        • Desperate efforts to avoid real or imagined abandonment
        • Unstable, intense interpersonal relationships
        • Unstable self-image
        • Impulsivity in at least two potentially harmful ways (spending, sexual

activity, substance use, etc.)

          • Recurrent suicidal threats or attempts or self-mutilation
          • Unstable mood/affect

 

  • General feeling of emptiness

 

          • Difficulty controlling anger
          • Transient, stress-related paranoid ideation or dissociative symptoms
      • EPIDEMIOLOGY
        • Prevalence: 1 to 2%
        • Women are two times as likely to have BPD as men.

 

  • 10% suicide rate

 

      • DIFFERENTIAL DIAGNOSIS
        • Schizophrenia: Unlike patients with schizophrenia, patients with borderline personality disorder do not have frank psychosis (may have transient psy- chosis, however, if decompensate under stress).
      • COURSE
        • Usually has a stable, chronic course.
        • High incidence of coexisting major de- pression and/or substance abuse;
        • increased risk of suicide (often because pa- tients will make suicide gestures and kill themselves by accident).
      • TREATMENT
        • Psychotherapy is the treatment of choice—behavior therapy, cognitive therapy, social skills training, and the like.
        • Pharmacotherapy to treat psychotic or depressive symptoms as necessary

 

  • Histrionic Personality Disorder (HPD)

 

      • Patients with HPD exhibit attention-seeking behavior and excessive emo- tionality.
      • They are dramatic, flamboyant, and extroverted but are unable to form long-lasting, meaningful relationships.
      • They are often sexually inappropriate and provocative.
      • DIAGNOSIS AND DSM-IV CRITERIA

 

  • Pattern of excessive emotionality and attention seeking, present by early adulthood and in a variety of contexts.

 

        • At least five of the following must be present:
        • Uncomfortable when not the center of attention
        • Inappropriately seductive or provocative behavior
        • Uses physical appearance to draw attention to self
        • Has speech that is impressionistic and lacking in detail
        • Theatrical and exaggerated expression of emotion
        • Easily influenced by others or situation
        • Perceives relationships as more intimate than they actually are
      • EPIDEMIOLOGY
        • Prevalence: 2 to 3%
        • Women are more likely to have HPD than men.
      • DIFFERENTIAL DIAGNOSIS
        • Borderline personality disorder: Patients with BPD are more likely to suffer from depression and to attempt suicide.
        • HPD patients are generally more functional.
      • COURSE
        • Usually has a chronic course, with some improvement of symptoms with age
      • TREATMENT
        • Psychotherapy is the treatment of choice.

 

  • Pharmacotherapy to treat associated depressive or anxious symptoms as necessary

 

    • Narcissistic Personality Disorder (NPD)
      • Patients with NPD have a sense of superiority, a need for admiration, and a lack of empathy.
      • They consider themselves “special” and will exploit others for their own gain.

 

  • Despite their grandiosity, however, these patients often have fragile self-esteems.

 

      • DIAGNOSIS AND DSM-IV CRITERIA
        • Pattern of grandiosity, need for admiration, and lack of empathy beginning by early adulthood and present in a variety of contexts.
        • Five or more of the fol- lowing must be present:
          • Exaggerated sense of self-importance
          • Preoccupied with fantasies of unlimited money, success, brilliance, etc.
          • Believes that he or she is “special” or unique and can associate only with other high-status individuals
          • Needs excessive admiration

 

  • Has sense of entitlement
  • Takes advantage of others for self-gain
  • Lacks empathy

 

          • Envious of others or believes others are envious of him or her
          • Arrogant or haughty
      • EPIDEMIOLOGY -Prevalence: < 1%
      • DIFFERENTIAL DIAGNOSIS
        • Antisocial personality disorder: Both types of patients exploit others, but NPD patients want status and recognition, while antisocial patients want material gain or simply the subjugation of others.
        • Narcissistic patients become de- pressed when they don’t get the recognition they think they deserve.
      • COURSE
        • Usually has a chronic course; higher incidence of depression and midlife crises since these patients put such a high value on youth and power.
      • TREATMENT

 

  • Psychotherapy is the treatment of choice.

 

      • Antidepressants or lithium may be used as needed (for mood swings if a comorbid mood disorder is diagnosed).

CLUSTER C

    • Includes avoidant, dependent, and obsessive–compulsive personality disorders.

 

  • These patients appear anxious and fearful.
  • Avoidant Personality Disorder

 

      • Patients with avoidant personality disorder have a pervasive pattern of social inhibition and an intense fear of rejection.
      • They will avoid situations in which they may be rejected.
      • Their fear of rejection is so overwhelming that it affects all aspects of their lives.
      • They avoid social interactions and seek jobs in which there is little interpersonal contact.
      • These patients desire companion- ship but are extremely shy and easily injured.
      • DIAGNOSIS AND DSM-IV CRITERIA
        • A pattern of social inhibition, hypersensitivity, and feelings of inadequacy since early adulthood, with at least four of the following:
        • Avoids occupation that involves interpersonal contact due to a fear of criticism and rejection
        • Unwilling to interact unless certain of being liked
        • Cautious of intrapersonal relationships
        • Preoccupied with being criticized or rejected in social situations
        • Inhibited in new social situations because he or she feels inadequate

 

  • Believes he or she is socially inept and inferior
  • Reluctant to engage in new activities for fear of embarrassment

 

      • EPIDEMIOLOGY -Prevalence: 1 to 10%
      • DIFFERENTIAL DIAGNOSIS
        • Schizoid personality disorder:

 

  • Patients with avoidant personality disorder de- sire companionship but are extremely shy, whereas patients with schizoid personality disorder have no desire for companionship.

 

        • Social phobia (social anxiety disorder):
          • Both disorders involve fear and avoidance of social situa- tions. If the symptoms are an integral part of the patient’s personality and have been evident since before adulthood, personality disorder is the more likely diagnosis.
          • Social phobia involves a fear of embarrassment in a particular setting (speaking in public, urinating in public, etc.), whereas avoidant personality disorder is an overall fear of rejection and a sense of inadequacy. However, a patient can have both disorders concurrently and should carry both diagnoses if criteria for each are met.
    • Dependent personality disorder:

 

  • Avoidant personality disorder patients cling to relationships, similar to dependent personality disorder patients; how- ever, avoidant patients are slow to get involved, whereas dependents ac- tively and aggressively seek relationships.

 

      • COURSE

 

  • Course is usually chronic.

 

        • Particularly difficult during adolescence, when attractiveness and socialization are important
        • Increased incidence of associated anxiety and depressive disorders
      • TREATMENT
        • Psychotherapy, including assertiveness training, is most effective.
        • Beta blockers may be used to control autonomic symptoms of anxiety, and selective serotonin reuptake inhibitors (SSRIs) may be prescribed for major depression.

 

  • Dependent Personality Disorder (DPD)

 

      • Patients with DPD have poor self-confidence and fear separation.
      • They have an excessive need to be taken care of and allow others to make decisions for them.

 

  • They feel helpless when left alone.

 

      • DIAGNOSIS AND DSM-IV CRITERIA
        • A pattern of submissive and clinging behavior due to excessive need to be taken care of.
        • At least five of the following must be present:
          • Difficulty making everyday decisions without reassurance from others
          • Needs others to assume responsibilities for most areas of his or her life
          • Cannot express disagreement because of fear of loss of approval
          • Difficulty initiating projects because of lack of self-confidence
          • Goes to excessive lengths to obtain support from others

 

  • Feels helpless when alone

 

          • Urgently seeks another relationship when one ends
          • Preoccupied with fears of being left to take care of self
      • EPIDEMIOLOGY
        • Prevalence: Approximately 1%
        • Women are more likely to have DPD than men.
      • DIFFERENTIAL DIAGNOSIS

 

  • Avoidant personality disorder:

 

        • Borderline and histrionic personality disorder:
          • Patients with DPD usually have a long-lasting relationship with one person on whom they are de- pendent.
          • Patients with borderline and histrionic personality disorders are often dependent on other people, but they are unable to maintain a long-lasting relationship.
      • COURSE
        • Usually has a chronic course
        • Often, symptoms decrease with age and/or with therapy.
        • Patients are prone to depression, particularly after loss of person on whom they are dependent.
      • TREATMENT
        • Psychotherapy is the treatment of choice.
        • Pharmacotherapy may be used to treat associated symptoms of anxiety or depression.

 

  • Obsessive–Compulsive Personality Disorder (OCPD)

 

      • Patients with OCPD have a pervasive pattern of perfectionism, inflexibility, and orderliness.
      • They get so preoccupied with unimportant details that they are often unable to complete simple tasks in a timely fashion.
      • They appear stiff, serious, and formal with constricted affect.
      • They are often successful professionally but have poor interpersonal skills.
      • DIAGNOSIS AND DSM-IV CRITERIA
        • Pattern of preoccupation with orderliness, control, and perfectionism at the expense of efficiency, present by early adulthood and in a variety of contexts.
        • At least four of the following must be present:
          • Preoccupation with details, rules, lists, and organization such that the major point of the activity is lost

 

  • Perfectionism that is detrimental to completion of task

 

          • Excessive devotion to work
          • Excessive conscientiousness and scrupulousness about morals and ethics
          • Will not delegate tasks

 

  • Unable to discard worthless objects
  • Miserly
  • Rigid and stubborn

 

      • EPIDEMIOLOGY
        • Men are more likely to have OCPD than women.
        • Occurs most often in the oldest child
        • Increased incidence in first-degree relatives
      • DIFFERENTIAL DIAGNOSIS
        • Obsessive–compulsive disorder (OCD):
          • Patients with OCPD do not have the recurrent obsessions or compulsions that are present in obsessive–compulsive disorder.
          • In addition, the symptoms of OCPD are ego-syntonic rather than ego-dystonic (as in OCD). That is, OCD patients are aware that they have a problem and wish that their thoughts and behaviors would go away.

 

  • Narcissistic personality disorder:
  • Both personalities involve assertiveness and achievement, but NPD patients are motivated by status, whereas OCD patients are motivated by the work itself.

 

    • COURSE
      • Unpredictable course
      • Some patients later develop obsessions or compulsions (OCD), some develop schizophrenia or major depressive disorder, and others may im- prove or remain stable.
    • TREATMENT
      • Psychotherapy is the treatment of choice. Group therapy and behavior therapy may be useful.
      • Pharmacotherapy may be used to treat associated symptoms as necessary.

PERSONALITY DISORDER NOT OTHERWISE SPECIFIED (NOS)

    • This diagnosis is reserved for personality disorders that do not fit into cate- gories A, B, or C.

 

  • It includes passive–aggressive personality disorder, depres- sive personality disorder, sadomasochistic personality disorder, and sadistic personality disorder.
  • Passive–Aggressive Personality Disorder

 

  • Patients with this disorder are stubborn, inefficient procras- tinators. They alternate between compliance and defiance and passively resist fulfillment of tasks.
  • They frequently make excuses for themselves and lack as- sertiveness. They attempt to manipulate others to do their chores, errands, and the like, and frequently complain about their own misfortunes.
  • Psychotherapy is the treatment of choice.