Personality traits are enduring patterns of perceiving, relating, &

thinking, displayed across various social and personal contexts.

Personality encompasses how individuals uniquely shape & adapt to ever-changing
internal & external environments.
Personality disorders arise only when traits become inflexible, maladaptive, causing
sig. impairment, or subjective distress (APA, 2013).

DEFINITION

Acc. to DSM-V, personality disorder has been defined as enduring pattern of inner
experience & behavior that deviates markedly from expectations of individual's
culture, is pervasive & inflexible, has an onset in adolescence or early adulthood, is
stable over time, & leads to distress or impairment.

NATURE

Personality disorders involve enduring patterns of inner experience & bhvr differing
markedly from cultural expectations, seen in at least 2 areas like cognition,
affectivity, interpersonal functioning, or impulse control.
These patterns are inflexible, pervasive across various situations, leading to sig.
distress or impairment in social, occupational, or important areas of life.
Onset traces back to adolescence or early adulthood, persisting & remaining stable
over time.
Diagnosis requires evaluating long-term patterns of functioning, distinct from
transient states due to situational stressors or other mental disorders.
Clinicians should assess stability of these traits across time & situations to
distinguish them from temporary mental states or responses to stressors.

TYPES

In DSM-V personality disorders are grouped into 3 clusters based on descriptive

similarities.
They were derived on basis of what were originally thought to be imp. similarities
of features among disorders within a given cluster.
CLUSTER A:
Includes paranoid, schizoid, and schizotypal personality disorders.
People with these disorders often seem odd or eccentric, with unusual behavior
ranging from distrust & suspiciousness to social detachment.
 CLUSTER B:
Includes histrionic, narcissistic, antisocial, & borderline personality disorders.
Individuals with these disorders share a tendency to be dramatic, emotional, &
erratic.
CLUSTER C:
Includes avoidant, dependent, & obsessive compulsive personality disorders.
In contrast to other 2 clusters, people with these disorders often show anxiety
& fearfulness.

CATEGORICAL & DIMENSIONAL MODEL

Personality disorders are debated as extreme variations of normal personality
traits (dimensions) or distinct ways of relating (categories).
DSM diagnostic approach categorizes personality disorders as qual. distinct clinical
syndromes, offering convenience and simplification.
Alternatively, dimensional perspective sees personality disorders as maladaptive
variants of traits blending into normality & each other.
This view suggests that individuals with personality disorders experience problems
that are more in degree than kind, potentially being extreme versions of temporary
problems experienced by many.

ISSUES & CHALLENGES

Culture-Related Diagnostic Issue:

Assessments of personality functioning should consider one's ethnic, cultural, &
social context.
Personality disorders should be distinguished from issues related to acculturation or
from expressions of cultural habits, customs, or religious/political values from person's
culture of origin

Gender-Related Diagnostic Issue:

Some personality disorders are diagnosed more frequently in specific genders,
possibly due to diagnostic bias, cultural differences in help-seeking behavior, &
societal tolerance.
Men diagnosed with personality disorders tend to exhibit traits like aggression,
structure, assertiveness, & detachment, while women often display characteristics of
submissiveness, emotionality, & insecurity
Historically, histrionic & borderline personality disorders were identified more in
women, but recent studies suggest equal prevalence between males & females in
the general population

Diagnosis-Related Issue:
Personality disorder diagnosis should reflect long-term functioning, not limited to
an episode of another mental disorder or substance use effects
While initially thought to begin in childhood & persist, newer insights suggest
personality disorders can remit over time, possibly replaced by others
Individuals might shift from 1 personality disorder diagnosis to another, but
limited research exists due to many seeking treatment only after years of distress,
making it hard to study early phases of these disorders.

ANTISOCIAL
PERSONALITY DISORDER

DIAGNOSTIC CRITERIA

A pervasive pattern of disregard for & violation of rights of others, occurring since
age 15 years, as indicated by 3 (or more) of following:
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, or conning others
for personal profit or pleasure.
Impulsivity or failure to plan ahead.
Irritability & aggressiveness, as indicated by repeated physical fights or assaults.
Reckless disregard for safety of self or others.
 Consistent irresponsibility, as indicated by repeated failure to sustain consistent
work behavior or honor financial obligations.
Lack of remorse, as indicated by being indifferent to or rationalizing having
hurt, mistreated, or stolen from another.

The individual is at least age 18 years.

There is evidence of conduct disorder with onset before age 15 years.

The occurrence of antisocial behavior is not exclusively during course of schizophrenia

or bipolar disorder.

Associated Features
frequently lack empathy & tend to be callous, cynical, & contemptuous of feelings,
rights, & sufferings of others.
may have an inflated & arrogant self-appraisal & may be excessively opinionated,
self-assured, or cocky.
may display a glib, superficial charm & can be quite voluble & verbally facile
may be indifferent to, or provide superficial rationalization for, having hurt,
mistreated, or stolen from someone.
frequently have a heightened sense of reality testing & often impress observers as
having excellent verbal intelligence.
tend to be manipulative, demanding, irresponsible, impulsive, & deceitful
often described as being aggressive because they take what they want, indifferent
to concerns of other people.
might exhibit irresponsibility in their roles as partners and parents, with history of
numerous sexual partners & no sustained monogamous relationships.
Many have chronic histories of institutionalization & repeated involvement in
criminal activities starting in adolescence & persisting into adulthood

DEFINING CRITERIA
Hervey Cleckley identified 16 major characteristics of "psychopathic personality,"
known as "Cleckley criteria."
The PCL-R criteria assess various aspects of psychopathy & are widely used in
evaluating this personality disorder.
Glibness/superficial charm
Grandiose sense of self-worth
Pathological lying
Conning/manipulative
Lack of remorse or guilt
Callous/lack of empathy
Need for stimulation
Shallow affect (superficial emotional responsiveness)
 Parasitic lifestyle
Poor behavioral controls
Sexual promiscuity
Early behavior problems
Lack of realistic long-term goals
Impulsivity
Irresponsibility
Failure to accept responsibility for own actions
Many short-term marital relationships
Juvenile delinquency
Revocation of conditional release
Criminal versatility

ONSET, COURSE & PROGNOSIS

ASPD diagnosis is for individuals aged 18 & older, requiring symptoms of conduct
disorder before age 15.
Diagnosis involves evidence of repeated unlawful behavior, deceitfulness, impulsivity,
aggressiveness, or consistent irresponsibility after 15.
ASPD follows chronic course but might become less pronounced or remit as individual
ages, particularly by their fourth decade.
Remission is notably evident in criminal bhvr, but decrease in full range of
antisocial behaviors & substance use is likely.
Peak of antisocial behavior typically occurs in late adolescence.

PREVALENCE
Prevalence is around 2-3%, more common in men.
Prevalence tends to be higher in groups affected by adverse socioeconomic or
sociocultural factors.

RISK & PROGNOSIS FACTORS

Familial Patterns & Risks:
1st-degree relatives have higher risk,
In families with ASPD, males tend to develop ASPD & substance use disorders, while
females more often exhibit Somatic Symptom Disorder.
These disorders show elevated prevalence compared to gen. pop. within such families.

Genetic & Environmental Factors:

Adoption studies suggest a combined influence of genetic & environmental factors in
development of ASPD.

Conduct Disorder & Associated Risks:

C.D before 10, along with ADHD, increases likelihood of ASPD in adulthood.
Progression likely with erratic parenting, neglect, or inconsistent parental
discipline.
 Gender Differences
ASPD is more prevalent in males than females.
Concerns exist about potential underdiagnosis in females due to an emphasis on
aggressive conduct disorder traits.

COMORBIDITY
Have a higher risk of premature violent death (e.g., suicide, accidents, homicides).
Often engage in risky sexual behavior & substance use, facing harmful consequences.
Individuals with ASPD may experience dysphoria, including tension, boredom
intolerance, & depressed mood.
Prone to impulse & conduct disorders, often accompanied by anxiety, depression,
substance use, somatic symptoms, & pathological gambling.
Common co-occurring personality disorders include Narcissistic, Borderline, &
Histrionic.

DIFFERENTIAL DIAGNOSIS
ASPD linked to substance use requires childhood signs persisting into adulthood, or
both starting in childhood and continuing.
Antisocial behavior within schizophrenia or bipolar disorders isn't considered ASPD.
ASPD shares traits with other disorders; distinctions are crucial based on
characteristic features.
ASPD differs from other disorders like Narcissistic, Histrionic, Borderline, & Paranoid
Personality Disorders.
ASPD should be distinguished from criminal behavior lacking its characteristic traits,
needing persistent, maladaptive traits for diagnosis.

CASE STUDY

David, a 28-year-old Caucasian male, entered treatment due to struggles with alcohol
and cocaine addiction, leading to an involuntary commitment after threats of self-harm
or harm to others. His complex history revealed eight prior inpatient admissions, five of
which were in the current facility, and a troubling cycle of incarceration for offenses like
larceny, assault, and drug possession. Before turning 18, he spent six months in a juvenile
detention center for assault. David's work history in construction involved numerous job
changes, and he described his family relationships as "distant," with limited support from
his mother, father, and two siblings. During therapy, he disclosed a history of childhood
physical abuse, expressing feeling secure for the first time in therapy but expressing
discomfort with group sessions, preferring individual therapy. He sought a delay in his
court date to complete treatment, seemingly displaying manipulation and charm to
persuade his counselor, indicative of possible Antisocial Personality Disorder (ASPD) traits
within his behavior.
 BORDERLINE PERSONALITY
DISORDER

Introduction:
Borderline Personality Disorder (BPD) was initially used for patients with symptoms
perceived to lie b/w neurosis & psychosis.
It's characterized by intense emotions, often fluctuating rapidly from anger to deep
depression.
Emotional dysfunction is considered key aspect & strong predictor of suicide risk
within this group.
Instability in emotion, relationships, self-concept, & behavior is core feature of BPD,
leading to term "stably unstable" by some experts.

DIAGNOSTIC CRITERIA:
Pervasive pattern of instability of interpersonal relationships, self-image, & affects,
& marked impulsivity, beginning by early adulthood & present in a variety of
contexts, as indicated by 5 (or more) of following:
Frantic efforts to avoid real or imagined abandonment. (Do not include suicidal
or self-mutilating behavior covered in Criterion 5.)
A pattern of unstable & intense interpersonal relationships characterized by
alternating b/w extremes of idealization & devaluation.
Identity disturbance: markedly & persistently unstable self-image/sense of self.
Impulsivity in at least 2 areas that are potentially self-damaging (spending,
sex, substance abuse, reckless driving, binge eating). (Same bracket as 1st.)
Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
Affective instability due to marked reactivity of mood (intense episodic dysphoria,
irritability, anxiety lasting few hours & only rarely more than few days).
Chronic feelings of emptiness.
Inappropriate, intense anger or difficulty controlling anger (frequent displays of
temper, constant anger, recurrent physical fights).
Transient, stress-related paranoid ideation or severe dissociation

Associated features:
Self-sabotage when nearing success; achievements fall short of potential.
Profound changes in self-image, mood, & behavior due to perceived rejection or loss.
Intense fear of abandonment, leading to inappropriate anger & feelings of being
"bad."
Tumultuous relationships due to dependency, idealization, & rapid shifts to
devaluation.
Quick shifts from idealizing to devaluing others based on perceived lack of care or
support.
Projective identification as a defense mechanism, projecting intolerable aspects onto
others.
Feeling more secure with transitional objects than in interpersonal relationships.

Onset, Course & Prognosis:

Diagnosis possible at 12 if symptoms persist for a year; treatment usually begins
around 18, although symptoms may start earlier.
BPD shows varied courses; common pattern involves chronic instability in early
adulthood, marked by affective dyscontrol & high health resource usage.
Highest risk of impairment & suicide in young-adult years; risk decreases with age.
Tendency toward intense emotions & impulsivity often lifelong, but therapeutic
intervention can lead to improvement within 1st year.
Most individuals experience greater stability in relationships & work during their
30s-40s.

Prevalence:
Prevalent in clinical settings across cultures, with median pop. prevalence of around
1.6%, potentially reaching up to 5.9%.
Prevalence varies across settings: 6% in primary care, 10% in outpatient mental
health clinics, and 20% in psychiatric inpatients.
BPD prevalence tends to decrease in older age groups.

RISK & PROGNOSIS FACTORS:

1st degree biological relatives of individuals with BPD have a 5x higher likelihood
of also having disorder compared to general population.
Also face increased familial risks for substance use disorders, ASPD, depressive/bipolar
disorders.
Individuals with BPD often have childhood histories involving physical & sexual
abuse, neglect, hostile conflict, & early parental loss.

Comorbidity:
About 6% of individuals with BPD commit suicide.
Among individuals with BPD, around 20% experience major depression, & 40% have
bipolar disorder.
About 25% of those with bulimia also have BPD, & up to 67% have at least 1
substance use disorder.
Co-occurring disorders include PTSD, ADHD, & other personality disorders like
schizotypal, narcissistic, & dependent disorders.

DIFFERENTIAL DIAGNOSIS:
Differs from mood disorders due to core symptoms- fear of abandonment, unstable
behavior, turbulent relationships, extreme perceptions of others, emptiness, & an
inconsistent self-identity.
 Distinct from identity issues, typically limited to developmental stages.
Differs from schizophrenia as BPD lacks prolonged psychotic episodes & thought
disorder.
Schizotypal disorder involves strange thinking & ideas of reference, while paranoid
disorder includes extreme suspicion. BPD usually has shorter-lived psychotic episodes,
if present.

Case Study:
Ms. R, a 19-year-old with no prior psychiatric treatment, presented with a history of
mood swings, self-harming behaviors like cutting, and suicidal tendencies. She had
tumultuous relationships, including experiences of physical abuse and multiple abortions.
Her admission to the hospital followed a threatening statement about self-harm post a
physical altercation with her boyfriend and a subsequent car crash. She described
feeling "depressed" after an altercation with her boyfriend, which escalated into a fight
with her mother, culminating in her stealing the family car and crashing it. Upon
admission, she expressed suicidal thoughts. Noted characteristics included anger,
entitlement, manipulation, and a sense of regression. Her diagnosis included borderline
personality disorder, with observed narcissistic traits (Avery et al., 2012).

GENDER DYSPHORIA

DEFINITION
Gender dysphoria refers to distress that may accompany incongruence b/w one's
experienced or expressed gender & one's assigned gender.
Although not all individuals will experience distress as result of such incongruence,
many are distressed if desired physical interventions by means of hormones and/or
surgery are not available.

TERMINOLOGY

Gender: The societal roles linked to being a boy, girl, man, or woman. Contrary to
some social theories, it recognizes interplay b/w biological, social, & psychological
factors in shaping gender development.
Gender assignment refers to the initial assignment as male or female. This occurs
usually at birth & thereby, yields "natal gender."
Gender-atypical: Somatic features/behaviours that are not typical (statisticaly) of
individuals with same assigned gender in a given society & historical era; for bhvr,
gender-nonconforming is an alternative descriptive term.
Gender reassignment denotes an official (usually legal) change of gender.
Gender identity: category of social identity & refers to an individual's identification
as male, female, or, occasionally, some category other than male or female.
Transgender refers to broad spectrum of individuals who transiently or persistently
identify with a gender different from their natal gender.
Transsexual: Individual who seeks, or has undergone, social transition from male to
female or vice-versa, which in many, but not all, also involves somatic transition by
cross-sex hormone treatment & genital surgery (sex reassignment surgery).

DIAGNOSTIC CRITERIA

It must be noted that there is 1 overarching diagnosis of gender dysphoria, with

separate developmentally appropriate criteria sets for children & for adolescents &
adults.

GENDER DYSPHORIA IN CHILDREN

A marked incongruence b/w 1's experienced/expressed gender & assigned gender, of
at least 6 months', as manifested by at least 6 of following (one of which must
be Criterion A1):
A strong desire to be of the other gender or an insistence that one is the other
gender.
In boys (A.G), strong preference for cross-dressing or simulating female attire; or
in girls (A.G), strong preference for wearing only typical masculine clothing & a
strong resistance to wearing of typical feminine clothing.
A strong preference for cross-gender roles in make-believe play or fantasy play.
A strong preference for toys, games, or activities stereotypically used or engaged
in by other gender.
A strong preference for playmates of other gender.
In boys (A.G), strong rejection of typically masculine toys, games, & activities &
a strong avoidance of rough-&-tumble play; or in girls (A.G), strong rejection of
typically feminine toys, games, and activities.
A strong dislike of one's sexual anatomy.
A strong desire for primary &/or secondary sex characteristics that match one's
experienced gender.

The condition is associated with clinically significant distress or impairment in

social, school, or other important areas of functioning.

Specify: if patient comes with a disorder of sex development.

GENDER DYSPHORIA IN ADOLESCENTS & ADULTS

A marked incongruence b/w one's experienced/expressed gender & assigned gender,

of at least 6 months' duration, as manifested by at least 2 of the following:
A marked incongruence b/w one's experienced/expressed gender & primary &/or
secondary sex characteristics
A strong desire to be rid of one's primary &/or secondary sex characteristics
because of marked incongruence with one's experienced/expressed gender
A strong desire for primary &/or secondary sex characteristics of other gender.
A strong desire to be of the other gender (or some alternative gender different
from one's assigned gender).
A strong desire to be treated as other gender
A strong conviction that 1 has typical feelings & reactions of other gender

The condition is associated with clinically significant distress or impairment in

social, occupational, or other important areas of functioning.

Specify if:
With a disorder of sex development (e.g., a congenital adrenogenital disorder).
Post Transition

IMPORTANT CHARACTERISTICS
Boys with gender dysphoria tend to engage in traditionally feminine activities, like
dressing in female clothing & playing with dolls or engaging in stereotypically
feminine play.
They avoid rough-&-tumble play & express strong desire to be identified as a girl.
Girls experiencing gender dysphoria typically prefer boys' clothing, shorter hair, &
show interest in male figures in their fantasies
They often have reduced interest in traditional feminine activities like playing with
dolls & exhibit an increased interest in sports.
Despite similar bhvrs seen in "tomboys," girls with gender dysphoria are characterized
by a desire to be a boy or grow up as a man.
Peer acceptance appears to be better for young girls with gender dysphoria compared
to boys, likely due to more tolerance toward cross-gender behavior in girls.

Onset, Course & Prognosis

Typically manifests in childhood b/w ages 2-4 but might emerge later, particularly
around puberty or in adulthood.
2 main paths in natal males: Early-onset, starting in childhood & continuing into
adulthood, or late-onset, occurring around puberty or later. Some recall childhood
desires; others don't report childhood gender dysphoria.
Persistence: Varies widely, with rates ranging from 2.2-50% in males & 12-50%
in females.
 Individuals with gender dysphoria often display different sexual orientations post-
transition, particularly males.
May result in early medical attention regarding gender assignment but does not
always lead to gender transition.

Prevalence
For natal adult males, prevalence rates 0.005-0.014%, & for natal females, from
0.002- 0.003%.

RISK & PROGNOSTIC FACTORS

Temperamental Factors: Early onset of atypical gender bhvr in preschool age might
contribute to gender dysphoria persisting into adolescence & adulthood.
Environmental Influences: Males with gender dysphoria often have more older
brothers compared to males without condition.
Genetic & Physiological Aspects: Weak familiality among nontwin siblings, increased
concordance in monozygotic twins, & some heritability suggest potential genetic
contribution.

SEX RATIO
In children, sex ratios of natal boys to girls range from 2:1 to 4.5:1.
In adolescents, the sex ratio is close to parity.
In adults, sex ratio favors natal males, with ratios ranging from 1:1 to 6.1:1.

Comorbidity:
Show elevated levels of emotional & behavioural problems—most commonly, anxiety,
disruptive & impulse-control, & depressive disorders.
Anxiety & depressive disorders being the most common.
Autism spectrum disorder is more prevalent in clinically referred adolescents with
gender dysphoria than in gen. pop.

DIFFERENTIAL DIAGNOSIS:
Nonconformity to gender roles- Distinguished from nonconformity to stereotypical
gender role behaviour.
Transvestic disorder Occasionally accompanied by gender dysphoria but not always.
Body dysmorphic disorder- Focuses on alteration/removal of specific body part because
perceived as abnormally formed, not because it represents assigned gender.
Schizophrenia & other psychotic disorders- There may rarely be delusions of
belonging to some other gender.
Othet Clinical Presentations: Males seeking castration or penectomy for non-gender-
related reasons do not fulfill these criteria.

Case Study:
Ms. T, a 24-year-old assigned female at birth, has harbored a profound desire to be male
since childhood. Encouraged by her father due to the absence of male siblings, she
embraced traditionally male behaviors and attire. As she matured, she developed an
attraction towards women, considering herself heterosexual within these relationships.
However, she consistently felt imprisoned within the wrong body, strongly believing her
emotions and responses aligned more with those of men. Engaging in a relationship with
a woman, where she identified as the male partner, she faced distress when her partner's
interests shifted towards men. Over the past 4–6 months, Ms. T has experienced
irritability, feelings of worthlessness, hopelessness, and made suicidal attempts. She now
expresses a fervent desire for surgery to transition to a male body, feeling that life is
intolerable trapped in a female form.

SEXUAL DYSFUNTION

Definition:
Heterogeneous group of disorders that are typically characterised by clinically sig.
disturbance in person's ability to respond sexually or to experience sexual pleasure
(APA, 2013).
An individual may have several sexual dysfunctions at the same time.

Essential Features: Daroon peene ke

Sexual dysfunctions entail an inability baad uttha nahi isilie
to respond to sexual stimulation or
experiencing pain during sexual activity. Biwi pareeshan hain
Dysfunction can manifest in a disturbance in -senti maam
the subjective sense of pleasure or desire associated with sex, or
in objective performance.
ICD-10 defines sexual dysfunction as the inability to engage in a
desired sexual relationship.
These dysfunctions affect both heterosexual & homosexual
couples, impacting enjoyment of sex for both partners in
a relationship.

Onset of Difficulty Classifications:

Lifelong onset: Sexual problems present from initial sexual experiences
Acquired onset: Sexual disorders developed after a period of normal
sexual function
Generalized subtype: Sexual difficulties not confined to specific stimulation,
situations, or partners
Situational subtype: Sexual issues occurring only with specific stimulation,
situations, or partners
Phases:
Researchers & clinicians typically identify 4 different phases of human sexual
response. According to DSM-5, disorders can occur in any of the 1st 3 phases:
Desire phase: consists of fantasies about sexual activity or a sense of desire to
have sexual activity.
Arousal, phase: It is characterized both by sub. sense of sexual pleasure & by
physiological changes that accompany subjective pleasure, including penile erection
in male & vaginal lubrication & clitoral enlargement in female.
Orgasm: during which there is a release of sexual tension & a peaking of sexual
pleasure.
Resolution: during which the person has a sense of relaxation and well-being.

Desire, Interest & Arousal

Male Hypoactive Sexual desire disorder:
Diagnosed in men who have for at least 6 months been distressed or impaired due
to low levels of sexual thoughts, desires, or fantasies.
Male Erectile Disorder or failure of genital response:
Formerly called impotence.
Now known as male erectile disorder & can be diagnosed only when difficulties are
considered to originate from either psychogenic or a combination of psychogenic and
medical factors.
Female Sexual Interest/Arousal Disorder:
For women, DSM-5 has combined dysfunctionally low desire with dysfunctionally low
sexual arousal in disorder.

Orgasm Disorders:
Female Orgasmic Disorder:
It can be diagnosed in women who are readily sexually excitable & who otherwise
enjoy sexual activity but show persistent or recurrent delay in or absence of orgasm
following a normal sexual excitement phase & who are distressed by this.
Delayed Ejacuation:
It refers to the persistent inability to ejaculate during intercourse.
Premature (Early) Ejaculation:
It is the the persistent & recurrent onset of orgasm and ejaculation with minimal
sexual stimulation.
It may occur before, on, or shortly after penetration & before man wants it to.
Orgasmic anhedonia (diagnosed as "other specified sexual dysfunction"):
Condition in which a person has no physical sensation of orgasm, even though the
physiologic component (e.g., ejaculation) remains intact.

Sexual Pain Disorders

Genito-Pelvic/Penetration Disorder:
Earlier versions distinguished 2 "sexual pain disorders": vaginismus & dyspareunia.
They have been combined in DSM-5 & it refers to genital pain of dyspareunia with
muscle tension (not muscle spasms) & fear & anxiety related to genital pain or
penetrative sexual activity.