DEPENDENT PERSONALITY DISORDER

(ANXIOUS/FEARFUL CLUSTER).

 Lack of self-confidence and a sense of autonomy

 They view themselves as weak and other people as powerful
 They have the intense need to be taken care of, which often
leads them to feel uncomfortable when alone; they may be
preoccupied with fears of being left alone to take care of
themselves
 They subordinate their own needs to ensure that they do not
break up the protective relationships they have established
 When a close relationship ends, they urgently seek another
relationship to replace the old one
 The DSM criteria portray people with independent personality
disorder as being very passive (e.g. having difficulty initiating
projects or doing things on their own, not being able to disagree
with others, allowing others to make decisions for them)
 The prevalence of dependent personality disorder is a little over
1,5%. It occurs more frequently among women
 Dependent personality disorder co-occurs frequently with
borderline, schizoid, histrionic, schizotypal, and avoidant
personality disorders as well as with the Axis I diagnoses of
bipolar disorder, depression, anxiety disorders, and bulimia
ALCOHOL ABUSE AND DEPENDENCE
People who are physically dependent on alcohol generally have
more severe symptoms of the disorder. Those who begin
drinking early in life develop their first withdrawal symptoms
in their thirties or forties. The effects of the abrupt withdrawal
of alcohol in a chronic, heavy user maybe rather dramatic
because the body has become accustomed to the drug.
Subjectively, the patient is often anxious, depressed, weak,
restless and unable to sleep. Tremors of the muscles, especially
of the small musculatures of the fingers, face, eyelids, lips, and
tongue, maybe marked, and pulse, blood pressure, and
temperature are elevated.
In relatively rare cases a person who has been drinking heavily
for a number of years may also experience delirium tremens
when the level of the alcohol drops suddenly. The person
becomes delirious as well as tremulus and has hallucinations
(primarily visual but may be tactile as well).
*Tolerance results from changes in the number or sensitivity of
GABA or glutamate receptors. When drinking stops, the
inhibitory effects of alcohol are lost, resulting in a state of
overexcitation. The drinking pattern of people who are alcohol
dependent indicates that their drinking is out of control.
Alcohol abuse or dependence is often part of polydrug abuse,
using or abusing more than one drug at the time. Polydrug
abuse can create serious health problems because the effects of
some drugs when taken together are synergistic. For example,
mixing alcohol e barbiturates is a common means of suicide,
intentional and accidental. Alcohol is also believed to
contribute to deaths of heroin, for it reduces the amount of the
narcotic needed to make a dose lethal.
Problem drinking is comorbid with several personality
disorders, mood disorders, other drug use, schizophrenia, and
anxiety disorders; it is also a factor in 25% of all suicides.
The initial effect of alcohol is stimulating, the drinker
experiences an expansive feeling of sociability and well-being
as his or her blood-alcohol levels rises. But after the blood-
alcohol level peaks and begins to decline, alcohol acts as a
depressant, and the person may experience increases in negative
emotions. Large amounts of alcohol interfere with complex
thought processes; motor coordination; balance; speech, and
vision are also impaired. At this stage of intoxication some
individuals become depressed mad withdrawn. Alcohol is also
capable of blunting pain and in larger doses, of inducing
sedation and sleep and even death.
Prolonged alcohol use plus reduction in the intake of proteins
contributes to the development of cirrhosis of the liver.
Other common physiological changes include damage to the
endocrine glands and pancreas, heart failure, hypertension,
stroke, and capillary hemorrhages.
Prolonged use of alcohol appears to destroy brain cells.
Alcohol also reduces the effectiveness of the immune system,
resulting in increased susceptibility to infection and cancer. For
example, women’s risk of breast cancer increases steadily with
the amount they drink.
Heavy alcohol consumption during pregnancy is the leading
known cause of mental retardation. The growth of the fetus is
slowed , and cranial, facial and limb abnormalities are
produced. The condition is known as fetal alcohol syndrome.

DRAMATIC/ERRATIC CLUSTER.

BORDERLINE PERSONALITY DISORDER

The core features of this disorder are impulsivity and instability

in relationships, mood, and self-image. For example, attitudes
an feelings toward other people may vary considerably and
inexplicably over short periods of time. Emotions are erratic
and can shift abruptly, particularly from passionate idealization
to contemptuous anger. Patients are argumentative , irritable,
sarcastic, quick to take offense, and altogether very hard to live
with. Their unpredictable impulsive behavior, which may
include gambling, spending, indiscriminate sexual activity, and
eating sprees, is potentially self-damaging.
These patients have not developed a clear and coherent sense of
self. They cannot bear abandonment, and demand attention.
Subject to chronic feelings of depression and emptiness, they
can often attempt suicide and attempt suicide and engage in
self-mutilating behavior, such as slicing into the legs with a
razor blade. Transient psychotic symptoms and dissociative
symptoms may appear in periods of high stress.
Originally the term implied that the person was on the
borderline between neurosis and schizophrenia. The DSM
concept of borderline personality disorder no longer has this
connotation.
Borderline personality disorder typically begins in early
adulthood, has a prevalence of 1 to 2%mand is more common
in women than men. Prognosis is not favorable. Borderline
patients are likely to have an Axis I mood disorder, and their
parents are more likely than average to have mood disorders.
Comorbidity is also found with substance abuse, PTSD, and
eating disorders, as well as with personality disorders from the
odd/eccentric cluster.
Kernberg (1985) proposes that adverse childhood experiences –
for example, having parents who provide love and attention
inconsistently, perhaps praising achievements but unable to
offer emotional support and warmth- cause children to develop
insecure egos, a major feature of borderline personality
disorder.
Linehan proposes that the disorder develops when people with a
biological diathesis (possibly genetic) of difficulty controlling
their emotions are raised in a family environment environment
that is invalidating.
An invalidating environment is one in which the person’s wants
and feelings are discounted and disrespected; efforts to
communicate one’s feelings are disregarded and even punished.
An extreme form of invalidation is child abuse, sexual and non-
sexual.

HISTRIONIC PERSONALITY DISORDER

The diagnosis of histrionic personality, formerly called

hysterical personality, is applied to people who are overly
dramatic and attention seeking. They often use features of their
physical appearance, such as unusual clothes, make up or hair
color to attract to themselves. These individuals, although
displaying emotion extravagantly, are thought to be emotionally
shallow. They are self-centered, overly concerned with their
physical attractiveness, and uncomfortable when they are not
the center of attention. They can be inappropriately sexually
provocative and seductive and are easily influenced by others.
Their speech is often impressionistic and lacking in detail. For
example, they may state a strong opinion yet be unable to give
any supporting information.
This diagnosis has a prevalence of 2 to 3% and is more
common among women and men. The prevalence is higher
among separated and divorced people , and it is associated with
higher rates of depression and poor physical health.
Comorbidity with borderline personality disorder is high.

NARCISSISTIC PERSONALITY DISORDER

People with narcissistic personality disorder have a grandiose

view of their uniqueness and abilities; they are preoccupied
with fantasies of great success. To say that they are self-
centered is an understatement. They require almost constant
attention and excessive admiration and believe that they can be
understood only by special and high-status people. Their
interpersonal relationships are disturbed by their lack of
empathy, feelings of envy, arrogance, and taking advantage of
others as well as by their feelings of entitlement- they expect
others to do special, not-to-be-reciprocated favors for them.
The prevalence of the disorder is less than 1%. It most often co-
occurs with borderline personality disorder.
Etiology: on the surface the person with narcissistic personality
disorder has a remarkable sense of self-importance, complete
self-absorption, and fantasies of limitless success, but it is
theorized, these characteristics mask a very fragile self-esteem.
Constantly seeking attention and adulation, narcissistic
personalities are extremely sensitive to criticism and deeply
fearful of failure. They generally do not allow anyone to be
genuinely close to them. Their personal relationships are few
and shallow; when people fall short of their unrealistic
expectations, people with narcissistic personality disorder (like
those borderline) become angry and rejecting. The inner lives
of these people are similarly impoverished because despite
their self-aggrandizement, they actually feel little of
themselves.
According to Kohut the self emerges early in life as a bipolar
structure with an immature grandiosity at one pole and a
dependent over idealization of other people at the other. A
failure to develop healthy self-esteem occurs when parents do
not respond with approval of their children’s displays of
competency; that is, the child is not valued for his or her own
self-worth but is valued as a means to foster the parents self-
esteem. When parents further their own needs rather than
directly approve of their children, the result, according to
Kohut, may be a narcissistic personality. Children neglected in
this way do not develop an internalized, healthy self-esteem and
have trouble accepting their own shortcomings. They develop a
narcissistic personality, striving to bolster their sense of self
through unending quests for love and approval of others.

ANTISOCIAL PERSONALITY DISORDER AND

PSYCHOPATHY( dramatic/erratic cluster).

ANXIOUS/FEARFUL CLUSTER:

This cluster comprises three personality disorders:

- Avoidant personality disorder applies to people who are
fearful in social situations.
- Dependent personality disorder refers to those who lack self-
reliance and are overly dependent on others.
- Obsessive-compulsive disorder applies to those who have a
perfectionistic approach to life.
AVOIDANT PERSONALITY DISORDER
The diagnosis of avoidant personality disorder applies to people
who are keenly sensitive to the possibility of criticism, rejection
or disapproval and are therefore reluctant to enter into
relationships unless they are sure to be liked. They may even
avoid employment that entails a lot of interpersonal contact. In
social situations they are restrained because of an extreme fear
of saying something foolish or of being embarrassed by
blushing or other signs of anxiety. They believe they are
incompetent and inferior to others and are reluctant to take risks
or try new activities.
The prevalence of avoidant personality disorder is about 1%,
and it is comorbid with dependent personality disorder.
Avoidant personality is also comorbid with the Axis I diagnose
of depression and generalized social phobia.

DEPENDENT PERSONALITY DISORDER (see

beginning)

OBSESSIVE-COMPULSIVE PERSONALITY DISORDER

The obsessive-compulsive personality is a perfectionist,
preoccupied with details, rules, schedules, and the like. These
people often pay so much attention to detail that they never
finish projects. They are work than pleasure oriented and have
inordinate difficulty making decisions and allocating time (lest
they focus on the wrong thing). Their interpersonal
relationships are often poor because they are stubborn and they
demand things are done their way. ‘Control freak’ is a popular
term for these individuals. They are generally serious, serious,
rigid, formal, and inflexible, especially regarding moral issues.
They are unable to discard worn-out and useless objects, even
those with no sentimental value, and are likely to be miserly
and stingy. A dysfunctional attention to work and productivity
is found more often in men than women.
The personality disorder has no obsessions or compulsions.
Obsessive-compulsive personality disorder is most highly
comorbid with avoidant personality disorder and has a
prevalence of 1%.
SOMATOFORM DISORDERS

Somatoform and dissociative disorders are related to anxiety

disorders. In somatoform disorders the individual complains of
bodily symptoms that suggest a physical defect or dysfunction -
sometimes rather dramatic in nature- but for which no
physiological basis can be found. In dissociative disorders, the
individual experiences disruptions of consciousness, memory
and identity. The onset of both classes of disorders is typically
related to some stressful experience, and these disorders
sometimes co-occur.
In somatoform disorders psychological problems take a
physical form. The physical symptoms of somatoform
disorders, which have no known physiological explanation and
are no under voluntary control, are thought to be linked to
psychological factors, presumably anxiety, and are therefore
assumed to be psychologically caused.
Somatoform disorders: PAIN DISORDER (Psychological
factors play a significant role in the onset of maintenance of
pain); BODY DYSMORPHIC DISORDER (Preoccupation
with imagined or exaggerated defects in physical appearance);
HYPOCHONDRIASIS ( Preoccupation with fears of having a
serious illness); CONVERSION DISORDERS ( Sensory or
motor symptoms without any physiological cause);
SOMATIZATION DISORDER ( Recurrent, multiple physical
complaints that have no biological basis).
*CONVERSION DISORDER
In conversion disorder, sensory or motor symptoms, such as a
sudden loss of vision or paralysis, suggest an illness related to
neurological damage of some sort, though the bodily organs
and nervous system are found to be fine. Individuals may
experience partial or complete paralysis of arms and legs;
seizures and coordination disturbances; a sensation of prickling,
tingling or creeping on the skin; insensitivity to pain; or the loss
or impairment of sensations, called anesthesias, although they
are physiologically normal people. Vision may be seriously
impaired; the person may become partially or completely blind
or have tunnel vision. Aphonia (loss of the voice and all but
whispered speech), and Anosmia (loss or impairment of the
sense of smell) are other conversion disorders.
The psychological nature of conversion symptoms is also
demonstrated by the fact that they appear suddenly in stressful
situations, allowing the individual to avoid some activity or
responsibility or to receive badly wanted attention. The term
conversion originally derived from Freud, who thought that the
energy of a repressed instinct was diverted in sensory-motor
channels and blocked functioning. This anxiety and
psychological conflict was believed to be converted into
physical symptoms.
*HYSTERIA = CONVERSION DISORDERS
Conversion symptoms