PERSONALITY

DISORDERS
BY:
DR ROSLIZA YAHAYA
PSYCHIATRIST, UNISZA.
LEARNING OUTCOME
At the end of this session, students should be able to
define and describe:
Personality disorders
Classification of personality disorder

At the end of this posting, students should be able

to identify and elicit:
Main clinical features of personality disorders
OVERVIEW OF THE TOPICS
PERSONALITY
DISORDERS:
An Introduction
Introduction
Personality disorders are common and chronic.
10-20% of the general population, and their duration is expressed
in decades.
~50% of all psychiatric patients have a personality disorder, which
is frequently comorbid with other clinical syndromes.
Personality disorder is also a predisposing factor for other
psychiatric disorders.
In general, personality disorder symptoms are:
ego syntonic
alloplastic
Do not feel anxiety about their maladaptive behaviour.
Do not routinely acknowledge pain from what others perceive as
their symptoms, they often seem disinterested in treatment and
impervious to recovery.
Personality Disorders
An enduring pattern of inner experience and behaviour that
deviates markedly from the expectations of the individual’s culture,
is pervasive and inflexible, has an onset in adolescence or early
adulthood, is stable over time, and leads to distress or impairment.
General Personality Disorder
A. An enduring pattern of inner experience and behaviour that deviates markedly
from the expectations of the individual’s culture. This pattern is manifested in
two (or more) of the following areas:
1. Cognition
2. Affectivity
3. Interpersonal functioning.
4. Impulse control.
B. The enduring pattern is inflexible and pervasive across a broad range of
personal and social situations.
C. Distress / Impaired functioning
D. Stable & long duration.
E. Rule out other mental disorders.
F. Rule out substance / AMC.
BIOLOGICAL FACTORS
Hormones:
Impulsive traits also often show high levels of testosterone, 17-
estradiol, and estrone.
Platelet Monoamine Oxidase:
Low platelet monoamine oxidase (MAO) levels have been
associated with activity and sociability
Smooth Pursuit Eye Movements:
Saccadic - introverted, who have low self-esteem and tend to
withdraw, and who have schizotypal personality disorder
BIOLOGICAL FACTORS
Neurotransmitters:
Reduce serotonin: depression, impulsiveness, and rumination
and can produce a sense of general well-being.
Increased dopamine concentrations in the central nervous
system can induce euphoria.
Electrophysiology:
Slow-wave activity on EEGs in antisocial and borderline types.
PSYCHOANALYTIC FACTORS
Defense mechanism (a part of…) :
Fantasy
Dissociation
Isolation
Projection
Splitting
Passive-aggression
Acting out
Projective identification
CLASSIFICATION OF PERSONALITY DISORDERS

CLUSTER A CLUSTER B CLUSTER C

CLUSTER A

Paranoid Personality Disorder

Schizotypal Personality Disorder
Schizoid Personality Disorder
Paranoid Personality Disorder
๏ Is a pattern of distrust and suspiciousness such that others’
motives are interpreted as malevolent.
๏ They refuse responsibility for their own feelings and assign
responsibility to others.
๏ They are often hostile, irritable, and angry.
Epidemiology
Prevalence: 2-4% of the general population.
Referred by : a spouse or an employer, they can often pull
themselves together and appear undistressed.
Higher incidence in relative patients with schizophrenia/delusional
disorder.
Men > Female
Higher in minority.
Course
First apparent in childhood and adolescence with solitariness, poor
peer relationships, social anxiety, underachievement in school,
hypersensitivity, peculiar thoughts and language, and idiosyncratic
fantasies.
These children may appear to be “odd” or “eccentric” and attract
teasing.
DIAGNOSTIC CRITERIA

A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as
malevolent, beginning by early adulthood and present in a variety of contexts, as indicated
by four (or more) of the following:
1. Suspects, without sufficient basis, that others are exploiting, harming,
or deceiving him or her.
2. Is preoccupied with 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 or her.
4. Reads hidden demeaning or threatening meanings into benign
remarks or events
DIAGNOSTIC CRITERIA

5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or

slights).
6. Perceives attacks on his or her character or reputation that are not
apparent to others and is quick to react angrily or to counterattack.
7. Has recurrent suspicions, without justification, regarding fidelity of spouse
or sexual partner.

B. RULE OUT other mental disorders / physiology / AMC

Differentials

Diagnosis In Paranoid PD person…

Delusional disorder the absence of fixed delusions

Schizophrenia no hallucinations or formal thought disorder

Borderline capable of overly involved, tumultuous relationships with others

Schizoid NOT withdrawn and aloof and do not have paranoid ideation
Treatment
Psychoeducation
Psychotherapy
Pharmacotherapy (Symptomatic):
Anxiousness: benzodiazepines
Severe agitation / delusional thinking - antipsychotics
Schizoid personality disorder
๏ Is a pattern of detachment from social relationships and a
restricted range of emotional expression.
๏ Often seen by others as eccentric, isolated, or lonely.
๏ Their discomfort with human interaction; their introversion; and
their bland, constricted affect are noteworthy
Epidemiology
Prevalence : affect 5% of the general population.
Male > female
Persons with the disorder tend to gravitate toward solitary jobs that
involve little or no contact with others.
Many prefer night work to day work so that they need not deal with
many persons
Course
First apparent in apparent in childhood and adolescence with
solitariness, poor peer relationships, and underachievement in
school, which mark these children or adolescents as different and
make them subject to teasing.
DIAGNOSTIC CRITERIA

A. A pervasive pattern of detachment from social relationships and a restricted range of

expression of emotions in interpersonal settings, beginning by early adulthood and
present in a variety of contexts, four (or more) of the following:
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.
4. Takes pleasure in few, if any, activities.
DIAGNOSTIC CRITERIA

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.

B. RULE OUT other mental disorders / physiology / AMC.

Differentials

Diagnosis In Schizoid PD person…

Schizophrenia/
The absence of delusions / hallucinations (+ve sx)
Delusional

Less social engagement, usually no history of aggressive verbal

Paranoid PD
behaviour, and a less tendency to project their feelings onto others

OC / Avoidant PD Less history of past object relations & more ‘autistic’ reverie

Less similar to a patient with schizophrenia in oddities of

Schizotypal
perception, thought, behaviour, and communication

Less impaired social interactions and stereotypical behaviors and

Autism
interests
Treatment
Psychoeducation
Psychotherapy
Pharmacotherapy (Symptomatic):
Anxiousness - benzodiazepines
Rejection - low dose of antipsychotics / antidepressants
Schizotypal personality disorder

๏ Is a pattern of acute discomfort in close relationships, cognitive or

perceptual distortions, and eccentricities of behaviour.
๏ Strikingly odd or strange, even to laypersons.
๏ Magical thinking, peculiar notions, ideas of reference, illusions, and
derealisation.
Epidemiology
Prevalence: 3% of the population.
Male > female
Higher in female with fragile X syndrome.
Greater association of cases exists among the biological relatives of
patients with schizophrenia.
Course
First apparent in childhood and adolescence with solitariness, poor
peer relationships, social anxiety, underachievement in school,
hypersensitivity, peculiar thoughts and language, and bizarre
fantasies.
These children may appear “odd” or “eccentric” and attract teasing.
DIAGNOSTIC CRITERIA
A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and
reduced capacity for, close relationships as well as by cognitive or perceptual distortions and
eccentricities of behaviour, beginning by early adulthood and present in a variety of
contexts,, as indicated by five (or more) of the following:
1. Ideas of reference (excluding delusions of reference).
2. Odd beliefs or magical thinking that influences behaviour and is
inconsistent with subcultural norms (e.g., superstitiousness, belief in
clairvoyance, telepathy, or “sixth sense”; in children and adolescents,
bizarre fantasies or preoccupations).
3. Unusual perceptual experiences, including bodily illusions.
4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical,
overelaborate, or stereotyped).
DIAGNOSTIC CRITERIA

5. Suspiciousness or paranoid ideation.

6. Inappropriate or constricted affect.
7. Behaviour or appearance that is odd, eccentric, or peculiar.
8. Lack of close friends or confidants other than first-degree relatives.
9. Excessive social anxiety that does not diminish with familiarity and tends
to be associate with paranoid fears rather than negative judgments about
self.
B. RULE OUT other mental disorders.
Differentials

Diagnosis In Schizotypal PD person…

Schizoid / Avoidant presence of oddities in their behaviour, thinking, perception, and

PD communication

Absence of psychosis.
Schizophrenia
If psychotic symptoms do appear, they are brief and fragmentary

Paranoid PD Less suspicious and more odd behaviours

Treatment
Psychoeducation
Psychotherapy
Pharmacotherapy (Symptomatic):
Anxiousness - benzodiazepines
Ideas of reference / illusions - low dose of antipsychotics
Depress - antidepressants
CLUSTER B

Antisocial Personality Disorder

Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
Antisocial personality disorder

is a pattern of disregard for, and violation of the rights of others.

Epidemiology
Prevalence 0.2-3%
> 70% in alcohol use disorder men & >75% prison population.
Boys > girls in larger family
Onset of the disorder is before the age of 15 years.
5x more common in 1st degree relatives.
Course
A chronic course but may become less evident or remit as the
individual grows older, particularly by the fourth decade of life.
Although this remission tends to be particularly evident with
respect to engaging in criminal behaviour, there is likely to be a
decrease in the full spectrum of antisocial behaviours and
substance use.
DIAGNOSTIC CRITERIA
A. A pervasive pattern of disregard for and violation of the rights of others, occurring since age
15 years, as indicated by three (or more) of the following:
1. Failure to conform to social norms with respect to lawful behaviours, as
indicated by repeatedly performing acts that are grounds for arrest.
2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning
others for personal profit or pleasure.
3. Impulsivity or failure to plan ahead.
4. Irritability and aggressiveness, as indicated by repeated physical fights
or assaults.
DIAGNOSTIC CRITERIA

5. Reckless disregard for safety of self or others.

6. Consistent irresponsibility, as indicated by repeated failure to sustain
consistent work behaviour or honour financial obligations.
7. Lack of remorse, as indicated by being indifferent to or rationalizing
having hurt, mistreated, or stolen from another.
B. The individual is at least age 18 years.
C. There is evidence of conduct disorder with onset before age 15 years.
D. The occurrence of antisocial behaviour is not exclusively during the course
of schizophrenia or bipolar disorder.
Differentials

Diagnosis In Antisocial PD person…

Illegal behaviour is part of gain and is accompanied by the rigid,

Criminal behavior
maladaptive, and persistent personality traits characteristic

Substance use As secondary / comorbid to the primary diagnosis.

Treatment
Psychoeducation
Psychotherapy
Pharmacotherapy (Symptomatic):
Anxiousness: benzodiazepines
ADHD - stimulants
Impulsivity - antiepileptic / mood stabiliser
Aggression - B-Adrenergic receptor antagonists
Borderline personality disorder

Is a pattern of instability in interpersonal relationships, self-image,

and affects, and marked impulsivity.
Epidemiology
Prevalence 1.6-5.9%, 6% in primary care setting, 10% OPD psychiatry
clinic, 20% inpatients psychiatry ward.
The prevalence of borderline personality disorder may decrease in
older age groups.
Course
The impairment from the disorder and the risk of suicide are greatest in the
young-adult years and gradually wane with advancing age.
Although the tendency toward intense emotions, impulsivity, and intensity
in relationships is often lifelong, individuals who engage in therapeutic
intervention often show improvement beginning sometime during the first
year.
During their 30s and 40s, the majority of individuals with this disorder attain
greater stability in their relationships and vocational functioning.
Patients can have short-lived psychotic episodes (so-called micro-psychotic
episodes) rather than full-blown psychotic breaks, and the psychotic
symptoms of these patients are almost always circumscribed, fleeting, or
doubtful.
DIAGNOSTIC CRITERIA
A. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and
marked impulsivity, beginning by early adulthood and present in a variety of contexts, as
indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include
suicidal or self-mutilating behaviour covered in Criterion 5.)
2. A pattern of unstable and intense interpersonal relationships characterised
by alternating between extremes of idealisation and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense
of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g.,
spending, sex, substance abuse, reckless driving, binge eating). (Note: Do
not include suicidal or self-mutilating behaviour covered in Criterion 5.)
DIAGNOSTIC CRITERIA
5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating
behaviour.
6. Affective instability due to a marked reactivity of mood (e.g., intense
episodic dysphoria, irritability, or anxiety usually lasting a few hours and
only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent
displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative
symptoms.
Differentials

Diagnosis In Borderline PD person…

NOT SO marked peculiarities of thinking, strange ideation, and

Schizotypal PD
recurrent ideas of reference

Schizophrenia Psychotic symptoms brief

Paranoid PD Less suspiciousness

Treatment
Psychoeducation
Psychotherapy:
Dialectic behaviour therapy
Mentalisation based therapy
Transference focused therapy
Cognitive behaviour therapy
Pharmacotherapy (Symptomatic):
Anxiousness- benzodiazepines
Aggression/psychosis - antipsychotics
Depress - antidepressant
Mood stabiliser
Histrionic personality disorder

๏ Is a pattern of excessive emotionality and attention seeking.

๏ Excitable and emotional and behave in a colourful, dramatic,
extroverted fashion.
๏ Accompanying their flamboyant aspects, however, is often an
inability to maintain deep, long-lasting attachments.
Epidemiology
Prevalence: 1-3%
10-15% have been reported in inpatient and outpatient mental
health settings.
Men > women
An association with somatisation disorder and alcohol use
disorders.
Course
With age, persons with histrionic personality disorder show fewer
symptoms.
Persons with this disorder are sensation seekers, and they may get
into trouble with the law, abuse substances, and act promiscuously.
DIAGNOSTIC CRITERIA
A. A pervasive pattern of excessive emotionality and attention seeking, beginning by early
adulthood and present in a variety of contexts, as indicated by five (or more) of the
following:
1. Is uncomfortable in situations in which he or she is not the centre of
attention.
2. Interaction with others is often characterised by inappropriate sexually
seductive or provocative behaviour.
3. Displays rapidly shifting and shallow expression of emotions.
4. Consistently uses physical appearance to draw attention to self.
DIAGNOSTIC CRITERIA

5. Has a style of speech that is excessively impressionistic and lacking

in detail.
6. Shows self-dramatisation, theatricality, and exaggerated expression
of emotion.
7. Is suggestible (i.e., easily influenced by others or circumstances).
8. Considers relationships to be more intimate than they actually are.
Differentials

Diagnosis In Histrionic PD person…

Less suicide attempts, identity diffusion, and brief psychotic

Borderline PD
episodes.

Somatisation
Co-occur
disorder

Brief psychotic /
Co-morbid
Dissociative DO
Treatment
Psychoeducation
Psychotherapy : Psychoanalytically-oriented
Pharmacotherapy (Symptomatic):
Anxiousness - benzodiazepines
Depression/somatic complaints - antidepressants
Illusions / derealisation - antipsychotics
Narcissistic personality disorder

๏ Is a pattern of grandiosity, need for admiration, and lack of

empathy.
๏ Heightened sense of self-importance, lack of empathy, and
grandiose feelings of uniqueness.
๏ Underneath, however, their self-esteem is fragile and vulnerable
to even minor criticism
Epidemiology
Prevalence: 1-6% community
May impart an unrealistic sense of omnipotence, grandiosity,
beauty, and talent to their children; thus, offspring of such parents
may have a higher than usual risk for developing the disorder
themselves.
Course
Constantly deal with blows to their narcissism resulting from their
own behaviour or from life experience.
Aging is handled poorly; patients value beauty, strength, and
youthful attributes, to which they cling inappropriately.
They may be more vulnerable, therefore, to midlife crises than are
other groups.
DIAGNOSTIC CRITERIA
A. A pervasive pattern of grandiosity (in fantasy or behaviour), 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:

1. Has a grandiose sense of self-importance (e.g., exaggerates
achievements and talents, expects to be recognised as superior without
commensurate achievements).
2. Is preoccupied with fantasies of unlimited success, power, brilliance,
beauty, or 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.
DIAGNOSTIC CRITERIA

5. Has a sense of entitlement (i.e., unreasonable expectations of especially

favourable 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 recognise 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 behaviours or attitudes.
Differentials

Diagnosis In Narcissistic PD person…

Borderline PD Less anxiety, less chaotic life and less likely attempt suicide.

Antisocial PD Less impulsive behaviour

Histrioninc PD More manipulative

Treatment
Psychoeducation
Psychotherapy
Pharmacotherapy (Symptomatic):
Depress - antidepressants
Mood swing - lithium
CLUSTER C

Avoidance Personality Disorder

Dependent Personality Disorder
Obsessive-compulsive
Personality Disorder
Avoidant personality disorder

๏ Is a pattern of social inhibition, feelings of inadequacy, and

hypersensitivity to negative evaluation.
๏ Such persons are commonly described as having an inferiority
complex
Epidemiology
Prevalence : 2-3% general population
Infants classified as having a timid temperament may be more
susceptible to the disorder than those who score high on activity
approach scales.
Course
Individuals who go on to develop avoidant personality disorder may
become increasingly shy and avoidant during adolescence and early
adulthood, when social relationships with new people become
especially important.
There is some evidence that in adults, avoidant personality disorder
tends to become less evident or to remit with age.
DIAGNOSTIC CRITERIA

A. 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:
1. Avoids occupational activities that involve significant interpersonal
contact because of fears of criticism, disapproval, or rejection.
2. Is unwilling to get involved with people unless certain of being liked.
3. Shows restraint within intimate relationships because of the fear of
being shamed or ridiculed.
4. Is preoccupied with being criticised or rejected in social situations.
DIAGNOSTIC CRITERIA

5. Is inhibited in new interpersonal situations because of feelings of

inadequacy.
6. Views self as socially inept, personally unappealing, or inferior to others.
7. Is unusually reluctant to take personal risks or to engage in any new
activities because they may prove embarrassing.
Differentials

Diagnosis In Avoidant PD person…

Histrionic /
NOT so demanding, irritable or unpredictable.
Borderline PD

Dependent PD More fear of abandonment.

Treatment
Psychoeducation
Psychotherapy
Pharmacotherapy (Symptomatic):
Anxiousness - benzodiazepines
Depress - antidepressants
Dependent personality disorder

๏ Is a pattern of submissive and clinging behaviour related to an

excessive need to be taken care of.
๏ Get others to assume responsibility for major areas of their lives,
lack self-confidence, and may experience intense discomfort
when alone for more than a brief period.
Epidemiology
Prevalence: 0.6%
Women > men
Persons with chronic physical illness in childhood may be most
susceptible to the disorder.
Course
Occupational functioning tends to be impaired because persons
with the disorder cannot act independently and without close
supervision.
Social relationships are limited to those on whom they can depend,
and many suffer physical or mental abuse because they cannot
assert themselves.
DIAGNOSTIC CRITERIA
A. A pervasive and excessive need to be taken care of that leads to submissive and clinging
behaviour and fears of separation, beginning by early adulthood and present in a variety of
contexts, as indicated by five (or more) of the following:
1. Has difficulty making everyday decisions without an excessive amount of
advice and reassurance from others.
2. Needs others to assume responsibility for most major areas of his or her
life.
3. Has difficulty expressing disagreement with others because of fear of loss
of support or approval. (Note: Do not include realistic fears of retribution.)
4. Has difficulty initiating projects or doing things on his or her own
(because of a lack of self-confidence in judgment or abilities rather than a
lack of motivation or energy).
DIAGNOSTIC CRITERIA

5. Goes to excessive lengths to obtain nurturance and support from others,

to the point of volunteering to do things that are unpleasant.
6. Feels uncomfortable or helpless when alone because of exaggerated
fears of being unable to care for himself or herself.
7. Urgently seeks another relationship as a source of care and support when
a close relationship ends.
8. Is unrealistically preoccupied with fears of being left to take care of
himself or herself
Differentials

Diagnosis In Dependent PD person…

Histrionic / have a long-term relationship with one person rather than a series
BorderlinePD of persons

Agoraphobia Less anxious or fear

Treatment
Psychoeducation
Psychotherapy
Pharmacotherapy (Symptomatic):
Anxiousness - benzodiazepines
Depress - antidepressants
Obsessive-compulsive personality disorder

Is a pattern of preoccupation with orderliness, perfectionism,

emotional constriction, perseverance, stubbornness, and
indecisiveness.
Epidemiology
Prevalence: 2-8 %.
Men > women
Oldest siblings
Patients often have backgrounds characterised by harsh discipline.
Course
Persons with obsessive-compulsive personality disorder may
flourish in positions demanding methodical, deductive, or detailed
work, but they are vulnerable to unexpected changes, and their
personal lives may remain barren.
DIAGNOSTIC CRITERIA
A. 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:
1. Is preoccupied with details, rules, lists, order, organisation, or schedules
to the extent that the major point of the activity is lost.
2. Shows perfectionism that interferes with task completion (e.g., is unable
to complete a project because his or her own overly strict standards are
not met).
3. Is excessively devoted to work and productivity to the exclusion of
leisure activities and friendships (not accounted for by obvious economic
necessity).
DIAGNOSTIC CRITERIA

4. Is overconscientious, scrupulous, and inflexible about matters of morality,

ethics, or values (not accounted for by cultural or religious identification).
5. Is unable to discard worn-out or worthless objects even when they have
no sentimental value.
6. Is reluctant to delegate tasks or to work with others unless they submit to
exactly his or her way of doing things.
7. Adopts a miserly spending style toward both self and others; money is
viewed as something to be hoarded for future catastrophes.
8. Shows rigidity and stubbornness.
Differentials

Diagnosis In OCPD person…

OCD ego-syntonic

Delusional disorder No fixed false belief

Hoarding Not so extreme hoarding things

Treatment
Psychoeducation
Psychotherapy
Pharmacotherapy (Symptomatic):
Anxiousness - benzodiazepines
OC symptoms - SSRIs