PERSONALITY DISORDERS

Liss V. Mariano, MD

PERSONALITY DISORDERS
A heterogenous group of disorders defined by longstanding, pervasive, and inflexible patterns of behavior
and inner experience.
They are manifested by at least two of the following
areas:

Cognition
Emotion
Relationships
Impulse control

Comorbidity rates for personality disorders are high.

> 1/2 meet the criteria for another PD

> 2/3rds meet the criteria for an Axis I disorder

Liss V Mariano, MD for ADMU

DSM-5 RESEARCH CRITERIA:

THE DIMENSIONAL APPROACH
Negative Affect
Detachment
Agreeableness/antagonism
Inhibition
Psychoticism

Liss V Mariano, MD for ADMU

DIMENSIONAL APPROACH:
FIVE-FACTOR MODEL
The dimensional approach involves rating each
individual on the five factors.
This avoids applying a categorical label which may
not completely fit
These personality traits form a continuum, and
individuals with PDs endorse the extremes.
High detachment linked to Cluster A PDs.
High antagonism linked to Cluster B PDs.

Liss V Mariano, MD for ADMU

PERSONALITY DISORDERS AT A GLANCE

Dramatic
& Erratic

Anxious &
Fearful

Paranoid
Schizoid
Schizotypal

Borderline
Histrionic
Narcissistic
Antisocial

Avoidant
Dependent
Obsessivecompulsive

Liss V Mariano, MD for ADMU

Odd &
Eccentric

CLUSTER A PERSONALITY
DISORDERS

CLUSTER A: PARANOID PD

Minimal positive symptoms

No cognitive disorganization
Less impairment in social
and occupational function

Liss V Mariano, MD for ADMU

Prevalence of 0.5 to 2.5%,

M>F
Characteristics include
suspiciousness of others,
expectations of being
maltreated, hostility, and
intense reactions to
perceived slights.
Differentiated from
schizophrenia in the ff
basis:

DSM-5 CRITERIA FOR PARANOID PD

1. suspects w/o sufficient basis, that others are

exploiting, harming, or deceiving him/her
2. is preoccupied w/ unjustified doubts about the
loyalty or trustworthiness of friends or associates
3. is reluctant to confide in others because of
unwarranted fear that the information will be used
maliciously against him/her

Liss V Mariano, MD for ADMU

A pervasive distrust & suspiciousness of

others such that their motives are
interpreted as malevolent, beginning by
early adulthood & present in a variety of
contexts, as indicated by 4 or more of the ff:

DSM-5 CRITERIA FOR PARANOID PD

4. reads hidden demeaning/threatening meanings into benign

remarks/events
5. persistently bears grudges, i.e., is unforgiving of insults,
injuries, or slights
6. perceives attacks on his/her character or reputation that
are not apparent to others & is quick to react angrily or to
counterattack
7. has recurrent suspicions, without justification, regarding
fidelity of spouse or sexual partner

Liss V Mariano, MD for ADMU

A pervasive distrust & suspiciousness of others

such that their motives are interpreted as
malevolent, beginning by early adulthood &
present in a variety of contexts, as indicated by 4
or more of the ff:

CLUSTER A: SCHIZOID PD

Liss V Mariano, MD for ADMU

Community prevalence of 7.5%

Persons who do not desire or
enjoy social relationships; they
appear dull, bland, and aloof.
They are often loners who
pursue solitary interests and
occupations, and are indifferent
to praise or criticism.
In fact, schizoid patients are
uncomfortable in social
situations and lack social
graces.
There is high comorbidity with
schizotypal, avoidant, and
paranoid PDs.

DSM-5 CRITERIA FOR SCHIZOID PD

1. neither desires nor enjoys close relationships,

including being part of a family.
2. almost always chooses solitary activities
3. has little, if any, interest in having sexual
experiences with another person

Liss V Mariano, MD for ADMU

A pervasive pattern of detachment from

social relationships & a restricted range of
expression of emotions in interpersonal
settings, beginning by early adulthood &
present in a variety of contexts, as
indicated by 4 or more of the ff:

DSM-5 CRITERIA FOR SCHIZOID PD

4. takes pleasure in few, if any, activities

5. lacks close friends or confidants other than first
degree relatives
6. appears indifferent to the praise or criticism of
others
7. shows emotional coldness, detachment, or flattened
affectivity

Liss V Mariano, MD for ADMU

A pervasive pattern of detachment from

social relationships & a restricted range of
expression of emotions in interpersonal
settings, beginning by early adulthood &
present in a variety of contexts, as
indicated by 4 or more of the ff:

CLUSTER A: SCHIZOTYPAL PD

They may also show paranoid

ideations, ideas of reference, and
confusing speech.

They may also have difficulties

in establishing relationships
which can be partly due to
their odd symptoms.
High comorbidity with other
PDs seen.

Liss V Mariano, MD for ADMU

Community prevalence of 3%
The most striking symptoms in
these patients include odd,
magical beliefs, recurrent
illusions, and eccentric
appearance.

DSM-5 CRITERIA FOR SCHIZOTYPAL PD

1. ideas of reference (excluding delusions of reference)

2. odd beliefs or magical thinking that influences
behavior & is inconsistent with subcultural norms
3. unusual perceptual experiences, including bodily
illusions
4. odd thinking & speech
5. suspiciousness or paranoid ideation

Liss V Mariano, MD for ADMU

A pervasive pattern of social & interpersonal

deficits marked by acute discomfort with, &
reduced capacity for, close relationships as
well as by cognitive or perceptual distortions
& eccentricities of behavior, beginning by
early adulthood & present in a variety of
contexts, as indicated by 5 or more of the ff:

DSM-5 CRITERIA FOR SCHIZOTYPAL PD

6. inappropriate or constricted affect

7. behavior/appearance that is odd, eccentric, or peculiar
8. lack of close friends or confidants other than 1st degree
relatives
9. excessive social anxiety that does not diminish w/
familiarity & tends to be associated w/ paranoid fears
rather than negative judgments about self

Liss V Mariano, MD for ADMU

A pervasive pattern of social & interpersonal

deficits marked by acute discomfort with, &
reduced capacity for, close relationships as
well as by cognitive or perceptual distortions
& eccentricities of behavior, beginning by
early adulthood & present in a variety of
contexts, as indicated by 5 or more of the ff:

BIOLOGICAL ETIOLOGY OF CLUSTER A PDS

Relatives of
schizophrenics have
increased risk for
schizotypal PD.
Patients with schizotypal
PD also have
neuroanatomical
abnormalities such as
enlarged ventricles.

Liss V Mariano, MD for ADMU

There is high
heritability seen for
these PDs.

CLUSTER B PERSONALITY
DISORDERS

HISTRIONIC PERSONALITY DISORDER

Prevalence: 3% of the population
Gender ratio: M<F
Characterized by extravagant,
intense, but shallow emotions.
Often termed theatrical due to
propensity to desire to be in the
center of attention.
Highly comorbid with
depression, borderline PD, and
medical problems.

Liss V Mariano, MD for ADMU

Liss V Mariano, MD for ADMU

DSM-5 CRITERIA FOR HISTRIONIC PD

Is uncomfortable in situations in which he or she is not the center of

attention
Interaction with others is often characterized by inappropriate
sexually seductive or provocative behavior
Displays rapidly shifting and shallow expression of emotions
Constantly uses physical appearance to draw attention to self
Has a style of speech that is excessively impressionistic and lacking
in detail
Shows self-dramatization, theatricality, and exaggerated expression
of emotion
Is suggestible, ie, easily influenced by others or circumstances
Considers relationships to be more intimate than they actually are

Liss V Mariano, MD for ADMU

A pervasive pattern of excessive emotionality and

attention seeking, beginning by early adulthood and
present in a variety of contexts, as indicated by 5 (or
more) of the ff:

PSYCHODYNAMICS OF HISTRIONIC PD

Females may have received

attention only for their physical
appearance or endearing
expressions of femininity.

Being the center of attention

may also be a way of
defending against low selfesteem.

Liss V Mariano, MD for ADMU

Family dynamics often reveal

a power distribution favoring
males.

BORDERLINE PERSONALITY DISORDER

This stems from the lack of a

coherent sense of self and can
lead to self-damaging behavior.

The disorder has also been

called:

Ambulatory schizophrenia
As-if personality
Pseudoneurotic schizophrenia
Psychotic character disorder
ICD 10: emotionally unstable
personality disorder

Liss V Mariano, MD for ADMU

Prevalence of 1-2%, with M:F

gender ratio of 1:2
Core features include
impulsivity, intensity, and
instability in relationships and
mood.

DSM-5 DIAGNOSTIC CRITERIA FOR

BORDERLINE PERSONALITY DISORDER
Liss V Mariano, MD for ADMU

A pervasive pattern of instability of interpersonal

relationships, self-image, and affects and marked impulsivity
by early adulthood and present in a variety of contexts, as
indicated by 5 (or more) of the ff:
Frantic efforts to avoid real or imagined abandonment.
A pattern of unstable and intense interpersonal relationships
characterized by alternating between extremes of idealization and
devaluation
Identity disturbance: markedly and persistently unstable selfimage or sense of self
Impulsivity in at least 2 areas that are potentially self damaging
(eg, spending, sex, substance abuse, reckless driving, binge eating)
Recurrent suicidal behavior, gestures or threats or self-mutilating
behavior

DSM-5 DIAGNOSTIC CRITERIA FOR

BORDERLINE PERSONALITY DISORDER

Affective instability due to a marked reactivity of mood (eg,

intense episodic dysphoria, irritability or anxiety usually
lasting few hours and only rarely more than a few days)
Chronic feelings of emptiness
Inappropriate, intense anger or difficulty controlling anger
(eg, frequent displays of temper, constant anger, recurrent
physical fights)
Transient, stress-related paranoid ideation or severe
dissociative symptoms

Liss V Mariano, MD for ADMU

A pervasive pattern of instability of interpersonal

relationships, self-image, and affects and marked impulsivity
by early adulthood and present in a variety of contexts, as
indicated by 5 (or more) of the ff:

BIOLOGICAL ETIOLOGY OF BORDERLINE PD

There is a high heritability

for borderline PD.

More than 60% of the

variance for the PD is
accounted for by genes.

Deficits in sensitivity to
serotonin may account for
impulsivity and emotional
dysregulation..

Liss V Mariano, MD for ADMU

NARCISSISTIC PERSONALITY DISORDER

Prevalence rates vary
across populations, with
M>F.
Persons with NPD have a
grandiose view of their
abilities and are
preoccupied with
fantasies of great success.

They have condescending

attitudes, dwell on
observable assets, and are
highly self-referential.

Most often co-occurs with

borderline PD.

Liss V Mariano, MD for ADMU

Liss V Mariano, MD for ADMU

DSM-5 CRITERIA FOR

NARCISSISTIC PERSONALITY DISORDER

1. Has a grandiose sense of self-importance (e.g. exaggerates

achievements and talents, expects to be recognized as
superior without commensurate achievements)
2. Preoccupied with fantasies of unlimited success, power,
brilliance, beauty, and ideal love
3. Believes that he or she is special and unique and can only
be understood by or should associate with other special or
high-status people or institutions
4. Requires excessive admiration

Liss V Mariano, MD for ADMU

A. A pervasive pattern of grandiosity (in

fantasy or behavior), need for admiration, and
lack of empathy, beginning by early adulthood
and present in a variety of contexts, as
indicated by five or more of the following:

DSM-5 Criteria for

Narcissistic Personality Disorder
Liss V Mariano, MD for ADMU

5. Has a sense of entitlement: i.e.

unreasonable expectations of especially
favorable treatment or automatic compliance
with his or her expectations
6. Is interpersonally exploitative: i.e. takes
advantage of others to achieve his or her own
ends
7. Lacks empathy: is unwilling to recognize or
identify with the feelings and needs of others
8. Is often envious of others or believes that
others are envious of him or her
9. Shows arrogant, haughty behaviors or
attitudes

PSYCHOSOCIAL ETIOLOGY OF NPD

Self-Psychology Model

Emotional coldness
Overemphasis on achievements

Liss V Mariano, MD for ADMU

Heinz Kohut theorized that narcissism masks a

decreased sense of self-worth
Parents of NPD patients failed to respond to
them with warmth and respect.
Parenting dimensions noted to increase risk:

ANTISOCIAL PERSONALITY DISORDER

(ASPD)

In prison populations, may be as

high as 75 percent

Characterized by an inability to
conform to the social norms
that govern aspects of peoples
adolescent and adult behavior.
Most common in poor urban
areas; familial pattern is
commonly present.
Most commonly comorbid with
substance abuse.

Liss V Mariano, MD for ADMU

Prevalence: 3 percent in men, 1

percent in women

DSM-5 DIAGNOSTIC CRITERIA FOR

ANTISOCIAL PERSONALITY DISORDER

Failure to conform to social norms with respect to lawful

behaviors as indicated by repeatedly performing acts that are
grounds for arrest
Deceitfulness as indicated by repeated lying, use of aliases for
personal profit or pleasure
Impulsivity
Irritability and aggressiveness (repeated physical fights or
assaults)
Reckless disregard for safety of self or others
Consistent irresponsibility
Lack of remorse

Liss V Mariano, MD for ADMU

There is a pervasive pattern of disregard for and

violation of the rights of others occurring since age
15 years, as indicated by 3 (or more) of the ff:

DSM-IV DIAGNOSTIC CRITERIA FOR

ANTISOCIAL PERSONALITY DISORDER

C.

D.

The individual is at least

18 years of age.
There is evidence of
conduct disorder with
onset before age 15
years.
The occurrence of
antisocial behavior is not
exclusively during the
course of schizophrenia
or a manic episode

Liss V Mariano, MD for ADMU

B.

ETIOLOGY OF ASPD

Genetic Factors

Heritability of antisocial behavior: 0.96

Genetic risk for AsPD, psychopathy, conduct
disorder, and substance use appear to be related.

Social Factors

In the family, high negativity, low warmth, and

parental inconsistency predict antisocial behavior.
Adverse family environments were related to the
development of AsPD.
Poverty and exposure to violence predict antisocial
behavior in children.

Liss V Mariano, MD for ADMU

CLUSTER C PERSONALITY
DISORDERS

AVOIDANT PERSONALITY DISORDER

Liss V Mariano, MD for ADMU

Prevalence <1%; M=F

Characterized by
inhibition, introversion,
and anxiety in social
situations which are driven
by fear of rejection and
feeling of inadequacy.
Also known as inadequate
personality disorder
80 percent may have
comorbid MDD; avoidant
patients also have high
risks for social phobia.

DSM-5 CRITERIA FOR

AVOIDANT PERSONALITY DISORDER

Avoids occupational activities that involve significant interpersonal

contact, because of fears of criticism, disapproval, rejection
Is unwilling to get involved in people unless certain of being liked
Shows restraint within intimate relationships because of the fear of
being shamed or ridiculed
Is preoccupied of being criticized or rejected in social situations
Is inhibited in new interpersonal situations because of feelings of
inadequacy
Views self as socially inept, personally unappealing, or inferior to
others
Is unusually reluctant to take personal risks or to engage in any new
activities because they may prove embarrassing

Liss V Mariano, MD for ADMU

A pervasive pattern of social inhibition, feelings of

inadequacy, and hypersensitivity to negative evaluation,
beginning by early adulthood and present in a variety of
contexts, as indicated by four or more of the following:

DEPENDENT PERSONALITY DISORDER

Prevalence: 3% in the
general population,
with M<F and higher
rates in socially
oriented cultures
Core features include
an overreliance on
others, an intense need
to be taken care of, and
a lack of self-confidence.

This may lead them to

subordinate their own
needs to ensure that the
relationship remains
stable.

Liss V Mariano, MD for ADMU

DSM-5 CRITERIA FOR

DEPENDENT PERSONALITY DISORDER

Has difficulty making everyday decisions without an

excessive amount of advice and reassurance from others
Needs other to assume responsibility for most major
areas of his or her life
Has difficulty expressing disagreement with others
because of fear of loss of support or approval
Has difficulty initiating projects or doing things on his or
her own

Liss V Mariano, MD for ADMU

A pervasive and excessive need to be taken

care of that leads to submissive and clinging
behavior and fears of separation, beginning by
early adulthood and present in a variety of
contexts, as indicated by five or more of the ff:

DSM-5 CRITERIA FOR

DEPENDENT PERSONALITY DISORDER

Goes to excessive lengths to obtain nurturance and support

from others, to the point of volunteering to do things that are
unpleasant
Feels uncomfortable or helpless when alone because of
exaggerated fears of being unable to take care of himself or
herself
Urgently seeking another relationship as a source of care and
support when a close relationship ends
Is unrealistically preoccupied with fears of being left to take
care of himself or herself

Liss V Mariano, MD for ADMU

A pervasive and excessive need to be taken care of

that leads to submissive and clinging behavior and
fears of separation, beginning by early adulthood
and present in a variety of contexts, as indicated by
five or more of the ff:

OBSESSIVE-COMPULSIVE PERSONALITY
DISORDER (OCPD)

Liss V Mariano, MD for ADMU

Prevalence: 1% of the
general population
M=F
Characterized by
perfectionism,
preoccupation with
details, interpersonal
control, and inflexibility.
Patients with OCPD do
not have obsessions and
compulsions.
Most frequently comorbid
with avoidant PD.

DSM-5 CRITERIA FOR

OBSESSIVE-COMPULSIVE PERSONALITY DISORDER

Preoccupied with details, rules, lists, order, organization, or

schedules to the extent the major point of the activity is lost
Shows perfectionism that interferes with task completion
Excessively devoted to work and productivity to the
exclusion of leisure activities and freindships
Overconscientious, scrupulous, and inflexible about matters
of morality, ethics, or values

Liss V Mariano, MD for ADMU

A pervasive pattern of preoccupation with

orderliness, perfectionism, and mental and
interpersonal control, at the expense of
flexibility, openness, and efficiency, beginning
by early adulthood and present in a variety of
contexts, as indicated by four or more of the
following:

DSM-5 CRITERIA FOR

OBSESSIVE-COMPULSIVE PERSONALITY DISORDER

Is unable to discard worn out worthless objects even when they

have no sentimental value
Is reluctant to delegate tasks or to work with others unless
they submit to his or her way of doing things
Adopts a miserly spending style toward both self and others;
money is viewed as something to be hoarded for future
catastrophes
Shows rigidity and stubbornness

Liss V Mariano, MD for ADMU

A pervasive pattern of preoccupation with

orderliness, perfectionism, and mental and
interpersonal control, at the expense of flexibility,
openness, and efficiency, beginning by early
adulthood and present in a variety of contexts, as
indicated by four or more of the following:

TREATMENT
OF PERSONALITY DISORDERS

TREATMENT OF PERSONALITY DISORDERS

Many persons with PD
actually enter treatment
because of an Axis I
disorder rather than a
personality disorder.
Medications may be used
to treat personality
disorders.

The choice of drug may be

determined by the Axis I
problem that the
personality disorder
resembles, for example, a
schizotypal patient may be
given an antipsychotic.

Liss V Mariano, MD for ADMU

TREATMENT OF PERSONALITY DISORDERS

Psychotherapy sessions may be done in an
outpatient basis or in a day treatment program.
Psychodynamic therapists aim to alter the
patients present-day views of the childhood
problems assumed to underlie the personality
disorder.

Brief psychodynamic treatment was shown to be

helpful in reducing symptoms of HPD and Cluster C
disorders.

Cognitive behavioral therapists break a PD down

into a set of separate problems, and address
these problems accordingly.

This may include systematic desensitization to

criticism or social skills training.

Liss V Mariano, MD for ADMU

MNEMONICS!!

PARANOID PD MNEMONIC: SUSPECT

Liss V Mariano, MD for ADMU

Spouse cheating
suspected
Unforgiving
Suspicious
Perceives attacks
Everyone is an
enemy
Confiding in others
is feared
Threats seen in the
harmless

SCHIZOID PD MNEMONIC: SIR SAFE

Sexual experience of
no interest
Activities are solitary
Friendships few
Emotionally cold

Liss V Mariano, MD for ADMU

Solitary lifestyle
Indifferent to
praise/criticism
Relationships of no
interest

SCHIZOTYPAL PD MNEMONIC: UFO AIDER

Affect inappropriate
Ideas of reference
Doubts others
Eccentric appearance or
behavior
Reluctant in social
situations

Liss V Mariano, MD for ADMU

Unusual perceptions
Friendless except for
family
Odd beliefs, thinking,
speech

HISTRIONIC PD MNEMONIC: I CRAVE SIN

Center of attention
Relationships are seen as more
intimate than they really are
Appearance is most important
Vulnerable to the suggestions of
others
Emotional expression is
exaggerated; theatricality and selfdramatization
Shifting, shallow emotions

Impressionistic manner of
speaking which lacks detail
(Novel situations are sought)

Liss V Mariano, MD for ADMU

Inappropriate behavior (seductive

or provocative)

MNEMONIC FOR BORDERLINE PD:

I RAISED A PAIN

Liss V Mariano, MD for ADMU

Identity disturbance
Relationships are unstable
Abandonment frantically
avoided
Impulsivity
Suicidal gestures
Emptiness
Dissociative Symptoms
Affective instability
Paranoid ideation
Anger poorly controlled
Idealization followed by
devaluation
Negativistic undermines
the efforts of self and
others

MNEMONIC FOR NPD: A FAME GAME

Liss V Mariano, MD for ADMU

Admiration is required in
excessive amounts
Fantasizes about unlimited
success, brilliance, beauty, etc.
Arrogant
Manipulative
Envious
Grandiose sense of selfimportance
Associates with special people
Me-first attitude
Empathy is lacking for others

MNEMONIC FOR ANTISOCIAL PERSONALITY

DISORDER: CALLOUS MAN

Liss V Mariano, MD for ADMU

Conduct disorder before age 15;

current age at least 18
Antisocial activities; commits
acts that are grounds for Arrest
Lies frequently
Lacks a superego
Obligations are not honored
Unstable cannot plan ahead
Safety of self and others is
ignored
Money lack thereof, spouse and
children unsupported
Aggressive, Assaultive
Not occurring during mania or
schizophrenia

AVOIDANT PD MNEMONIC: AURICLE

Liss V Mariano, MD for ADMU

Avoids activities
Unwilling to get
involved
Restrained within
relationships
Inhibited in
interpersonal situations
Criticism expected in
social situations
Lower than others
Embarrassment the
feared emotion

DEPENDENT PD MNEMONIC: NEEDS PUSH

Preoccupied with fears of

being left to care for self
Urgently seeks another
relationship
Self-confidence lacking
Helpless when alone

Liss V Mariano, MD for ADMU

Needy
Expression of disagreement
with others limited
Excessive need for
nurturance and support
Decision making is difficult
Self-motivation

OBSESSIVE-COMPULSIVE PD MNEMONIC:
PERFECTION

Liss V Mariano, MD for ADMU

Preoccupied with details,

plans, organization
Emotionally restricted
Reluctant to delegate tasks
Frugal
Excessively devoted to work
Controls others
Task completion hampered
by perfectionism
Inflexible
Overconscientious about
morals, ethics, values, etc
Not able to discard
belongings; hoards objects

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