PERSONALITY DISORDERS

Personality Disorders
• a common and chronic disorder
• prevalence is estimated between 10 and 20 % in the general population
• its duration is expressed in decades
• frequently labeled as aggravating, demanding, or parasitic
• generally considered to have poor prognosis
• approx. half of all psychiatric patients have personality disorder
• also a predisposing factor for other psychiatric disorders (e.g., substance
use, suicide, affective disorders, impulse-control disorders, eating disorders,
and anxiety disorders)
• far more likely to refuse psychiatric help and to deny their problems than
persons with anxiety disorders, depressive disorders, or obsessive-
compulsive disorder
• symptoms are alloplastic (i.e., able to adapt to, and alter, the external
environment) and ego-syntonic (i.e., acceptable to the ego)
• do not feel anxiety about their maladaptive behavior
• CLASSIFICATION
– personality disorders as enduring subjective
experiences and behavior that deviate from cultural
standards, are rigidly pervasive, have an onset in
adolescence or early adulthood, are stable through
time, and lead to unhappiness and impairment
– Subtypes are:
• Cluster A : odd, aloof features
– schizotypal, schizoid, and paranoid
• Cluster B : dramatic, impulsive and erratic features
– narcissistic, borderline, antisocial, and histrionic
• Cluster C : anxious and fearful features
– avoidant, dependent, obsessive-compulsive
– many persons exhibit traits that are not limited to a
single personality disorder
 Etiology
• Genetic Factors
– among monozygotic twins, the concordance for personality disorders was
several times that among dizygotic twins
– monozygotic twins reared apart are about as similar as monozygotic
twins reared together
– Cluster A: more common in the biological relatives of patients with
schizophrenia
– Cluster B: have a genetic base
• ASPD is associated with alcohol use disorders
• depression is common in the family backgrounds of patients with BPD
• strong association is found between histrionic personality disorder and
somatization disorder (Briquet's syndrome); patients with each disorder show an
overlap of symptoms
– Cluster C: often have high anxiety levels
• OC traits are more common in monozygotic twins
• patients with OCPD show some signs associated with depression: shortened rapid
eye movement (REM) latency period and abnormal dexamethasone-suppression
test (DST) results
• Biological Factors
– Hormones
• Persons who exhibit impulsive traits also often show
high levels of testosterone, 17-estradiol, and estrone
– Platelet Monoamine Oxidase
• College students with low platelet MAO levels report
spending more time in social activities than students
with high platelet MAO levels; also noted in some
patients with schizotypal disorders
– Smooth Pursuit Eye Movements
• are saccadic (i.e., jumpy) in persons who are
introverted, who have low self-esteem and tend to
withdraw, and who have schizotypal personality
disorder
– Neurotransmitters
• Endorphins have effects similar to those of exogenous
morphine, such as analgesia and the suppression of
arousal
• Levels of 5-HIAA, a metabolite of serotonin, are low in
persons who attempt suicide and in patients who are
impulsive and aggressive
– Electrophysiology
• Changes in electrical conductance on the
electroencephalogram (EEG) occur in some patients
with personality disorders, most commonly antisocial
and borderline types; these changes appear as slow-
wave activity on EEGs
• Psychoanalytic Factors
– Sigmund Freud: personality traits are related to a
fixation at one psychosexual stage of development
– Wilhelm Reich: coined the term character armor to
describe persons' characteristic defensive styles for
protecting themselves from internal impulses and
from interpersonal anxiety in significant relationships
– When defenses work effectively, persons with
personality view their behavior as ego-syntonic; that
is, it creates no distress for them, even though it may
adversely affect others
• In addition to characteristic defenses in personality
disorders, another central feature is internal object
relations.
– During development, particular patterns of self in relation
to others are internalized
– Through introjection, children internalize a parent or
another significant person as an internal presence that
continues to feel like an object rather than a self
– Through identification, children internalize parents and
others in such a way that the traits of the external object
are incorporated into the self and the child “owns” the
traits
– persons with personality disorders are also identified by
particular patterns of interpersonal relatedness that stem
from these internal object relations patterns
 Defense Mechanisms

• Fantasy
– persons who are often labeled schizoid, those who
are eccentric, lonely, or frightened seek solace and
satisfaction within themselves by creating
imaginary lives, especially imaginary friends
– the unsociableness of these patients rests on a
fear of intimacy
– rather than criticizing them or feeling rebuffed by
their rejection, therapists should maintain a quiet,
reassuring, and considerate interest without
insisting on reciprocal responses
• Dissociation
– Dissociation or denial is a Pollyanna-like
replacement of unpleasant affects with pleasant
ones
– persons who frequently dissociate are often seen
as dramatizing and emotionally shallow; may be
labeled histrionic personalities
– these patients are often inadvertent liars, but they
benefit from ventilating their own anxieties and
may in the process “remember” what they
“forgot”
– Often therapists deal best with dissociation and
denial by using displacement
• Isolation
– characteristic of the orderly, controlled persons
who are often labeled OC personalities
– remember the truth in fine detail but without
affect
– such patients respond well to precise, systematic,
and rational explanations and value efficiency,
cleanliness, and punctuality as much as they do
clinicians' effective responsiveness
• Projection
– patients attribute their own unacknowledged
feelings to others
– The technique of counterprojection is especially
helpful
• Clinicians acknowledge and give paranoid patients full
credit for their feelings and perceptions; they neither
dispute patients' complaints nor reinforce them, but
agree that the world described by patients is
conceivable
• Splitting
– persons toward whom patients' feelings are, or
have been, ambivalent are divided into good and
bad
• Passive Aggression
– Persons turn their anger against themselves
– this phenomenon is called masochism and
includes failure, procrastination, silly or
provocative behavior, self-demeaning clowning,
and frankly self-destructive acts
– hostility in such behavior is never entirely
concealed
• Acting Out
– patients directly express unconscious wishes or
conflicts through action to avoid being conscious of
either the accompanying idea or the affect
– Ex: Tantrums, apparently motiveless assaults, child
abuse, and pleasureless promiscuity
– Because the behavior occurs outside reflective
awareness, acting out often appears to observers to
be unaccompanied by guilt, but when acting out is
impossible, the conflict behind the defense may be
accessible
• Projective Identification
– appears mainly in borderline personality disorder
and consists of three steps
• First, an aspect of the self is projected onto someone
else.
• The projector then tries to coerce the other person into
identifying with what has been projected.
• Finally, the recipient of the projection and the projector
feel a sense of oneness or union.
DSM-5 General Diagnostic Criteria for a Personality Disorder

A. An enduring pattern of inner experience and behavior that deviates markedly from
the expectations of the individual's culture. This pattern is manifested in two (or more)
of the following areas:
– cognition (i.e., ways of perceiving and interpreting self, other people, and events)
– affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)
– interpersonal functioning
– impulse control
B. The enduring pattern is inflexible and pervasive across a broad range of personal and
social situations.
C. The enduring pattern leads to clinically significant distress or impairment in social,
occupational and other areas of functioning.
D. The pattern is stable and of long duration, and its onset can be traced back at least to
adolescence or early adulthood.
E. The enduring pattern is not better accounted for as a manifestation or consequence of
another mental disorder.
F. The enduring pattern is not due to the direct physiological effects of a substance (e.g.,
a drug of abuse, a medication) or a general medical condition (e.g., head trauma).
 Paranoid Personality Disorder
• characterized by long-standing suspiciousness and mistrust of
persons in general
• refuse responsibility for their own feelings and assign responsibility
to others
• often hostile, irritable, and angry
• bigots, injustice collectors, pathologically jealous spouses, and
litigious cranks often have paranoid personality disorder
• prevalence : 0.5 to 2.5% of the general population
• relatives of patients with schizophrenia show a higher incidence of
paranoid personality disorder
• M>W
• no familial pattern
• higher among minority groups, immigrants, and persons who are
deaf
 DSM-5 Diagnostic Criteria for Paranoid Personality Disorder

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:
– suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her
– is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or
associates
– is reluctant to confide in others because of unwarranted fear that the information will be used
maliciously against him or her
– reads hidden demeaning or threatening meanings into benign remarks or events
– persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights
– perceives attacks on his or her character or reputation that are not apparent to others and is
quick to react angrily or to counterattack
– has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner
B. Does not occur exclusively during the course of schizophrenia, a mood disorder with
psychotic features, or another psychotic disorder and is not due to the direct
physiological effects of a general medical condition.
Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” e.g.,
“paranoid personality disorder (premorbid).”
• Differential Diagnosis
– delusional disorder by the absence of fixed delusions.
– paranoid schizophrenia
– borderline personality disorder b
– antisocial behavior of persons with antisocial character
– schizoid personality disorder

• Course and Prognosis

– paranoid personality disorder is lifelong; in others, it is
a harbinger of schizophrenia
– have lifelong problems working and living with others
– occupational and marital problems are common
• Treatment
– Psychotherapy
• the treatment of choice for paranoid personality
– Pharmacotherapy
• in dealing with agitation and anxiety
• antianxiety agent
• antipsychotic in small dosages and for brief periods to
manage severe agitation or quasi-delusional
 Schizoid Personality Disorder

• in patients who display a lifelong pattern of social

withdrawal
• their discomfort with human interaction, their
introversion, and their bland, constricted affect are
noteworthy
• often seen by others as eccentric, isolated, or lonely
• Prevalence: may affect 7.5% of the general
population
• 2:1=male:female
• tend to gravitate toward solitary jobs that involve
little or no contact with others
 DSM-5 Diagnostic Criteria for Schizoid Personality Disorder

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, as indicated by four (or more) of
the following:
– neither desires nor enjoys close relationships, including being part of a family
– almost always chooses solitary activities
– has little, if any, interest in having sexual experiences with another person
– takes pleasure in few, if any, activities
– lacks close friends or confidants other than first-degree relatives
– appears indifferent to the praise or criticism of others
– shows emotional coldness, detachment, or flattened affectivity
B. Does not occur exclusively during the course of schizophrenia, a mood disorder
with psychotic features, another psychotic disorder, or a pervasive
developmental disorder and is not due to the direct physiological effects of a
general medical condition.
Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,”
e.g., “schizoid personality disorder (premorbid).”
• Differential Diagnosis
– Schizophrenia
– delusional disorder
– affective disorder with psychotic features
– paranoid personality disorder
– obsessive-compulsive personality disorder
– avoidant personality disorder
– schizotypal personality disorder
– avoidant personality disorder
– autistic disorder
– Asperger's syndrome

• Course and Prognosis

– Early childhood onset
– long lasting, but not necessarily lifelong
• Treatment
– Psychotherapy
– Pharmacotherapy
• with small dosages of antipsychotics, antidepressants,
and psychostimulants
• Benzodiazepines may help diminish interpersonal
anxiety
 Schizotypal Personality Disorder

• strikingly odd or strange, even to laypersons

• magical thinking, peculiar notions, ideas of
reference, illusions, and derealization are part
of a schizotypal person's everyday world
• occurs in about 3% of the population
• sex ratio is unknown
• greater association of cases exists among the
biological relatives of patients with
schizophrenia and a higher incidence among
monozygotic twins than among dizygotic twins
 DSM-5 Diagnostic Criteria for Schizotypal Personality
Disorder
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 behavior, beginning by early adulthood and present in a
variety of contexts, as indicated by five (or more) of the following:
– ideas of reference (excluding delusions of reference)
– odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms
(e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense†; in children and
adolescents, bizarre fantasies or preoccupations)
– unusual perceptual experiences, including bodily illusions
– odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped)
– suspiciousness or paranoid ideation
– inappropriate or constricted affect
– behavior or appearance that is odd, eccentric, or peculiar
– lack of close friends or confidants other than first-degree relatives
– excessive social anxiety that does not diminish with familiarity and tends to be associated with
paranoid fears rather than negative judgments about self
B. Does not occur exclusively during the course of schizophrenia, a mood disorder with
psychotic features, another psychotic disorder, or a pervasive developmental disorder.
Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” e.g.,
“schizotypal personality disorder (premorbid).”
• Differential Diagnosis
– schizoid personality disorder
– avoidant personality disorders
– schizophrenia
– borderline personality disorder.
– paranoid personality disorder

• Course and Prognosis

– Thomas McGlashan: 10% of those with schizotypal
personality disorder eventually committed suicide
– schizotype is the premorbid personality of the patient with
schizophrenia
– some maintain a stable schizotypal personality throughout
their lives and marry and work, despite their oddities
• Treatment
– Psychotherapy
– Pharmacotherapy
• antipsychotic
• antidepressants
 Antisocial Personality Disorder

• an inability to conform to the social norms that ordinarily govern many

aspects of a person's adolescent and adult behavior
• although characterized by continual antisocial or criminal acts, the
disorder is not synonymous with criminality
• prevalence: 3% in men and 1% in women
• most common in poor urban areas and among mobile residents of these
areas
• boys with the disorder come from larger families than girls with the
disorder
• onset: before the age of 15
• a familial pattern is present
• 5x more common among first-degree relatives of men with the disorder
• Hervey Cleckley’s term, the mask of sanity
• they appear to lack a conscience
 DSM-5 Diagnostic Criteria for Antisocial Personality Disorder

A. There is 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:
– 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 and 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
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 behavior is not exclusively during the course of
schizophrenia or a manic episode.
• Differential Diagnosis
– adult antisocial behavior
– substance abuse
– mental retardation
– schizophrenia
– Mania

• Course and Prognosis

– runs an unremitting course, with the height of antisocial behavior
usually occurring in late adolescence
– prognosis varies
– some reports indicate that symptoms decrease as persons grow older
– many patients have somatization disorder and multiple physical
complaints
– depressive disorders, alcohol use disorders, and other substance
abuse are common
• Treatment
– Psychotherapy
• self-help groups have been more useful than jails in
alleviating the disorder

– Pharmacotherapy
• Psychostimulants
• antiepileptic drugs
• beta2-adrenergic receptor antagonists
 Borderline Personality Disorder
• stand on the border between neurosis and psychosis
• has also been called ambulatory schizophrenia, as-if personality
(a term coined by Helene Deutsch), pseudoneurotic
schizophrenia (described by Paul Hoch and Phillip Politan), and
psychotic character disorder (described by John Frosch)
• ICD-10 uses the term emotionally unstable personality disorder
• characterized by extraordinarily unstable affect, mood, behavior,
object relations, and self-image
• present in about 1-2% of the population
• 2x as common in women as in men
• increased prevalence of MDD, alcohol use disorders, and
substance abuse is found in first-degree relatives of persons with
borderline personality disorder
 DSM-5 Diagnostic Criteria for Borderline Personality Disorder

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: frantic efforts to avoid real or imagined
abandonment. Note: Do not include suicidal or self-mutilating behavior covered in
Criterion 5.
• a pattern of unstable and intense interpersonal relationships characterized by alternating
between extremes of idealization and devaluation
• identity disturbance: markedly and persistently unstable self-image or sense of self
• 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 behavior covered in Criterion 5.
• recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
• affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria,
irritability, or anxiety usually lasting a few hours and only hours and only rarely more than
a few days)
• chronic feelings of emptiness
• inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of
temper, constant anger, recurrent physical fights)
• transient, stress-related paranoid ideation or severe dissociative symptoms
• Clinical Features
– almost always appear to be in a state of crisis;
mood swings are common
– can have short-lived psychotic episodes (so-called
micropsychotic episodes) rather than full-blown
psychotic breaks, and the psychotic symptoms of
these patients are almost always circumscribed,
fleeting, or doubtful
– the painful nature of their lives is reflected in
repetitive self-destructive acts
– persons with this disorder have tumultuous
interpersonal relationships
• Otto Kernberg : defense mechanism of
projective identification ; intolerable aspects of
the self are projected onto another; the other
person is induced to play the projected role, and
the two persons act in unison
• They distort their relationships by considering
each person to be either all good or all bad
• Some clinicians use the concepts of panphobia,
pananxiety, panambivalence, and chaotic
sexuality to delineate these patients'
characteristics.
• Differential Diagnosis
– Schizophrenia
– schizotypal personality disorder
– paranoid personality disorder
• Course and Prognosis
– fairly stable; patients change little over time
– no progression toward schizophrenia, but patients
have a high incidence of MDD
• Treatment
– Psychotherapy
– Pharmacotherapy
• Anxiolytics, antidepressants, antipsychotics, mood
stabilizers
 Common Features of Recommended Psychotherapy for Borderline
Personality Disorder

• Therapy is not expected to be brief.

A strong helping relationship develops between patient and
therapist.
Clear roles and responsibilities of patient and therapist are
established.
Therapist is active and directive, not a passive listener.
Patient and therapist mutually develop a hierarchy of
priorities.
Therapist conveys empathic validation plus the need for
patient to control his/her behavior.
Flexibility is needed as new circumstances, including stresses,
develop.
Limit setting, preferably mutually agreed upon, is used.
Concomitant individual and group approaches are used.
 Histrionic Personality Disorder

• excitable, emotional and behave in a colorful, dramatic,

extroverted fashion
• accompanying their flamboyant aspects, however, is
often an inability to maintain deep, long-lasting
attachments
• may have a psychosexual dysfunction; women may be
anorgasmic, and men may be impotent
• major defenses: repression and dissociation
• Prevalence: 2-3%
• W>M
• an association with somatization disorder and alcohol
use disorders
 DSM-5 Diagnostic Criteria for Histrionic Personality Disorder

• 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:
– 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
– consistently 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, i.e., easily influenced by others or circumstances
– considers relationships to be more intimate than they actually are
• Differential Diagnosis
– borderline personality disorder I
– somatization disorder (Briquet's syndrome)
– brief psychotic disorder
– dissociative disorders

• Course and Prognosis

– with age, persons with histrionic personality
disorder show fewer symptoms
– sensation seekers, and they may get into trouble
with the law, abuse substances, and act
promiscuously
• Treatment
– Psychotherapy
• Psychoanalytically oriented psychotherapy (group or
individual) - probably the treatment of choice
– Pharmacotherapy
• antidepressants
• antianxiety
• antipsychotics
 Narcissistic Personality Disorder

• characterized by a heightened sense of self-

importance and grandiose feelings of
uniqueness
• Prevalence: 2-16% (in the clinical population);
less than 1% in the general population
• may impart an unrealistic sense of omnipotence,
grandiosity, beauty, and talent to their children
• offspring of such parents may have a higher than
usual risk for developing the disorder
themselves
 DSM-5 Diagnostic Criteria for Narcissistic Personality Disorder
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:

• has a grandiose sense of self-importance (e.g., exaggerates achievements and talents,

expects to be recognized as superior without commensurate achievements)
• is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal
love
• 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)
• requires excessive admiration
• has a sense of entitlement, i.e., unreasonable expectations of especially favorable
treatment or automatic compliance with his or her expectations
• is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own
ends
• lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
• is often envious of others or believes that others are envious of him or her
• shows arrogant, haughty behaviors or attitudes
• Differential Diagnosis
– Borderline, histrionic, and antisocial personality
disorders often accompany narcissistic personality
disorder
• Course and Prognosis
– chronic and difficult to treat
– aging is handled poorly
– more vulnerable to midlife crises
• Treatment
– Psychotherapy
• Kernberg and Heinz Kohut have advocated using
psychoanalytic approaches to effect change
• group therapy
– Pharmacotherapy
• Lithium , antidepressants
 Avoidant Personality Disorder
• show extreme sensitivity to rejection and may lead a
socially withdrawn life
• shy, though not asocial and show a great desire for
companionship
• need unusually strong guarantees of uncritical
acceptance
• described as having an inferiority complex (ICD-10:
anxious personality disorder)
• common
• prevalence: 1-10%
• no sex ratio or familial pattern
 DSM-5 Diagnostic Criteria for Avoidant Personality Disorder
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 criticized or rejected in social situations
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
• Differential Diagnosis
– schizoid personality disorder
– borderline personality disorder
– histrionic personality disorders
– dependent personality disorder

• Course and Prognosis

– able to function in a protected environment.
– phobic avoidance is common
• Treatment
– Psychotherapy
– Pharmacotherapy
• used to manage anxiety and depression
– beta2-adrenergic receptor antagonists
– serotonergic agents
 Dependent Personality Disorder
• subordinate their own needs to those of others, 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
• has been called passive-dependent personality
• an oral-dependent personality dimension characterized
by dependence, pessimism, fear of sexuality, self-doubt,
passivity, suggestibility, and lack of perseverance
• W>M
• more common in young children than in older ones
• persons with chronic physical illness in childhood may be
most susceptible to the disorder
 DSM-5 Diagnostic Criteria for Dependent Personality Disorder
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 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)
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
• Differential Diagnosis
– histrionic personality disorder
– borderline personality disorder
– schizoid personality disorder
– schizotypal personality disorder
– can occur in patients with agoraphobia

• Course and Prognosis

– Occupational functioning tends to be impaired
– social relationships are limited to those on whom they can
depend
– many suffer physical or mental abuse because they cannot
assert themselves
– risk MDD if they lose the person on whom they depend
– with treatment, the prognosis is favorable
• Treatment
– Psychotherapy
• Insight-oriented therapies
• Behavioral therapy, assertiveness training, family
therapy, and group therapy
– Pharmacotherapy
• anxiolytics and antidepressants
• Psychostimulants may be used
 Obsessive-Compulsive Personality Disorder

• characterized by emotional constriction, orderliness,

perseverance, stubbornness, and indecisiveness
• a pervasive pattern of perfectionism and inflexibility
• ICD-10: anancastic personality disorder
• Prevalence: unknown
• M>W
• diagnosed most often in oldest children
• more frequently in first-degree biological relatives of
persons with the disorder
• have backgrounds characterized by harsh discipline
• Freud: associated with difficulties in the anal stage of
psychosexual development, generally around the age of 2
 DSM-5 Diagnostic Criteria for Obsessive-Compulsive Personality Disorder

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, organization, 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)
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
• Differential Diagnosis
– OCD

• Course and Prognosis

– course is variable and unpredictable
– the disorder can be either the harbinger of
schizophrenia or exacerbated by the aging process
in MDD
• Treatment
– Psychotherapy
• often aware of their suffering
• they seek treatment on their own
– Pharmacotherapy
• Clonazepam
• serotonergic
• Nefazodone may benefit some patients
 DSM-5 Research Criteria for Passive-Aggressive Personality
Disorder
A.A pervasive pattern of negativistic attitudes and passive
resistance to demands for adequate performance, beginning by
early adulthood and present in a variety of contexts, as indicated
by four (or more) of the following:
– passively resists fulfilling routine social and occupational tasks
– complains of being misunderstood and unappreciated by others
– is sullen and argumentative
– unreasonably criticizes and scorns authority
– expresses envy and resentment toward those apparently more fortunate
– voices exaggerated and persistent complaints of personal misfortune
– alternates between hostile defiance and contrition
B.Does not occur exclusively during major depressive episodes and
is not better accounted for by dysthymic disorder.
 DSM-5 Research Criteria for Depressive Personality Disorder

A.A pervasive pattern of depressive cognitions and behaviors

beginning by early adulthood and present in a variety of
contexts, as indicated by five (or more) of the following:
– usual mood is dominated by dejection, gloominess, cheerlessness,
joylessness, unhappiness
– self-concept centers around beliefs of inadequacy, worthlessness, and
low self-esteem
– is critical, blaming, and derogatory toward self
– is brooding and given to worry
– is negativistic, critical, and judgmental toward others
– is pessimistic
– is prone to feeling guilty or remorseful
B.Does not occur exclusively during major depressive episodes
and is not better accounted for by dysthymic disorder.
DSM-5 Diagnostic Criteria for Personality Disorder Not Otherwise
Specified

This category is for disorders of personality functioning that

do not meet criteria for any specific personality disorder. An
example is the presence of features of more than one
specific personality disorder that do not meet the full
criteria for any one personality disorder (“mixed
personality”, but that together cause clinically significant
distress or impairment in one or more important areas of
functioning (e.g., social or occupational). This category can
also be used when the clinician judges that a specific
personality disorder that is not included in the classification
is appropriate. Examples include depressive personality
disorder and passive-aggressive personality disorder.
Others
• Sadomasochistic Personality Disorder
• Sadistic Personality Disorder
• Personality Change due to a GMC