Personality disorder, Habit

and impulse disorder,

Gender identity disorder
H.M.Zainie Hassan A.R.
dr.SpKJ(K)
 WHAT IS Character
traits/Personality traits?
• Freud(1913) distinguished between neurotic
symptoms and personality/ character traits.
• Character traits owe their existence to the
success of repression, that is , to the defense
system that achieves its aim through a
persistent pattern of reaction formation and
sublimation.
• Character and personality are used
interchange ably. Character is influenced by
constitutional temperament.
 DSM-IV-TR(Diagnostic and Statistic Manual of
Mental Disorders)
• Personality : A person’s totality of emotional and
behavioural traits apparent in ordinary
life, that usually stable and predictable

• if differ & exceeds the range of variation found in
most people , and
• if personality traits are rigid, maladaptive &
produce functional impairment, subjective distress

Personality disorders
 DSM-IV-TR(Diagnostic and Statistic Manual of
Mental Disorders)

• Enduring subjective experiences &

behaviour that deviate from
cultural standards
• Rigidly pervasive
• Onset in adolescence / early adulthood
• Stable through time
• Lead to unhappiness & impairment
 Personality disorders are grouped
into three clusters in DSM-IV-TR
• Cluster A covers the paranoid, schizoid, and
schizotypal personality disorders;often perceived
as odd and eccentric.
• Cluster B is made up of the antisocial,
borderline, histrionic, and narcissistic personality
disorders; often seem dramatic, emotional, and
erratic.
• Cluster C includes the avoidant, dependent,
obsessive compulsive, passive agressive,
depressive personality disorder; often seem
anxious or fearful.
 ICD 10 - PPDGJ 3

• Specific personality disorders

( paranoid, schizoid ,
dissocial,emotionally unstable :
impulsiveborderline, histrionic,
anankastic, anxious / avoidant,
dependent, other & unspecified )
 DISORDER OF PERSONALITY AND
BEHAVIOUR (F69 - F69)

• F. 60 Specific personality disorders

• F. 62 Enduring personality changes , not attributable to brain
damage and disease
• F. 63 Habit and impulse disorders
• F. 64 Gender identity disorders
• F. 65 Disorder of sexual preference
• F. 66 Psychological and behavioural disorders associated with
sexual development and orientation
• F. 68 Other disorders of adult personality and behaviour
F. 60 Specific personality disorders
Criteria
ICD 10 - PPDGJ 3
• Severe disturbance of personality and behaviour that are
pronounced deviations from normal cultural patterns
• Disturbance of long standing duration in several areas of
functioning
• Pervasive , maladaptive behaviour
• Onset in childhood / adolescence & continuation into adulthood
• Considerable personality distress
• Usually significant problems in work & social behaviour
General Characteristics

• Alloplastic
• Ego syntonic
• Do not feel anxious - disturbed due to the maladaptive
behaviour
 deny problems , refuse (psychiatric) help,
disinterested in treatment , impervious to
recovery
Classification
ICD 10 - PPDGJ 3
• Specific personality disorders ( paranoid, schizoid ,
dissocial, emotionally unstable : impulsive , borderline,
histrionic, anankastic, anxious / avoidant,
dependent, other & unspecified )

DSM IV
• Cluster A : paranoid , .schizoid, schizotypal : odd &
eccentric
• Cluster B : antisocial, borderline, histrionic, narcissistic :
dramatic, emotional, erratic.
• Cluster C : avoidant, dependent, obsessive - compulsive,
passive - aggressive, depressive : anxious, fearful
Etiology
Genetic - Biological
• Concordance mono  dizygotic twins
• Cluster A more common among biological relatives of SR patients;
B apparently have a genetic base; C, probably
• Testosterone , 17 estradiol, estrone : impulsive traits
• Androgens : aggressions & sexual behaviour
• MAO : low platelet level  sociability
• Endorphins   phlegmatic
• Serotonin   depression , impulsiveness  , rumination, sense of

wellbeing 
• Dopamine : euphoria
• EEG : slow wave activity  antisocial, borderline personality disorders
Psychological
• Fixation at one psychosexual stage of development
(oral : passive dependent, anal : stubborn , highly conscientious )
• Defense mechanisms : unconscious mental processes that ego
uses to resolve conflicts among four important aspects of inner life
(instinct, reality, important people and conscience )  each
human being’s unique stamp of personality is considered largely
determined by his / her characteristic defense mechanisms
(schizoid: fantasy; histrionic: dissociation; paranoid: projection etc).

•Temprament, Familial, Environmental

Fearful children  avoidant personality, childhood MBD 
antisocial personality, poor parental fit, cultural factors etc.
Types of specific personality disorder
Paranoid
• 0.5 - 2.5 % of gen. pop, M  F, minority groups,
immigrants, deaf people .
• Early adulthood pervasive suspiciousness, mistrust,
pathological jealousy, hostile, irritable, angry, ideas
of reference, lack of warmth, arrogant.
• DD/ delusional disorder, paranoid SR
• Lifelong , occupational, marital problems
• Psychotherapy : straightforward, no defensive explanation,
limited interpretation , limitation of intimacy
• Pharmacotherapy : diazepam, haloperidol, thioridazine.
Schizoid
• 7.5 % of gen pop. M : F = 2 : 1 , solitary jobs, night workers
• Very limited eye contact, inappropriately serious, short answers, no
spontaneous conversation, cold, aloof, quiet, distant, seclusive,
unsociable, introvert , eccentric , lonely, little need for emotional
ties (human being) , prefer solitary non-competitive jobs, threats
faced by fantasy or resignation, heterosexual relations postponed
indefinitely.
• DD/ SR, schizotypal pers. dis.
• Onset in early childhood , long lasting, SR ?
• Psychotherapy : individual, group (respect pt silency & solitarian attitude )
• Pharmacotherapy : anti psychotics , antidepressant (SSRI), psycho
stimulants
Schizotypal *
• 3 % of gen pop, mono > dizygotic twins (33% : 4 %),
> biol relatives of SR.
• Odd, strange, thinking & communication disturbed
(magical-peculiar way of thinking) , speech has a personal
meaning & often need interpretation, sensitive to negative
feeling of others, ideas of reference, derealization, may act
inappropriately , claim of having special abilities, illusion.
• DD / SR, schizoid pers dis
• Lifelong , 10 % committed suicide, SR.
• Psychotherapy : do not ridicule pt strange activities
• Pharmacotherapy : haloperidol, antidepressant
Dissocial ( antisocial * )
• 3 % of men , 1 % of women in the gen. pop. ( 75 % of prison pop); poor
urban areas ( mobile residents); onset < 15 y.o.a.
• Composed, credible, charming, ingratiating, lying, truancy, running away
from home, thefts, fights, substance abuse, illegal activities
(beginning in childhood) , seductive, manipulative, demanding,
untrustworthy, spouse & child abuse, promiscuity, no anxiety /
depression / remorse, abn EEG, soft neurological signs
• DD / Criminality, MR, SR, Affective dis (mania)
• Unremitting course (peak : adolescence )
• Psychotherapy : firm limits.
• Pharmacotherapy : cautiously
(anti anxiety, antidepressant, psychostimulants , DA, anti epileptic )
Emotionally unstable pers dis : Impulsive,
Borderline
( Borderline* )
• 1 - 2 % of the gen pop. M : F = 1 : 2
• In the border between neurosis & psychosis (panphobia , pananxiety ,
panambivalence , chaotic sexuality) , almost always in state of crisis,
extraordinary unstable affect-mood - behaviour - self image , mood
swings, micro psychotic episodes, highly unpredictable behaviour, self
destructive acts, tumultuous interpersonal relations, frantic need of
companionship, feeling of emptiness, boredom , depression .
• DD/ SR , schizotypal pers. dis.
• Change little over time
• Psychotherpy ( individual , group : hospital setting ), behaviour therapy
• Pharmacotherapy : anti - psychotics, - depressant - convulsant .
• Impulsive type : emotional instability, lack of impulse
control; outburst of violence or threatening behaviour are
common, esp. in response to criticism by others
(explosive personality dis)
• Borderline type
Histrionic
• 2-3% of gen pop
• Attention seeking behaviour, excitable, emotional,
colorful, dramatic, extroverted, exagerate thoughts &
feelings, dependent, superficial-manipulative
relationships, seductive, but usually also have
psychosexual dysfunction; under stress, reality testing
easily impaired
• DD/ Borderline pers dis, somatization dis
• Age , symptoms  (lack of energy); sensation seekers
 trouble with the law, PAS abuse, promiscuity
• Psychotherapy
• Pharmacotherapy : antidepressant, antianxiety,
antipsychotic
Anankastic/Obsessive-Compulsive
• M > F; 1st degree biol relatives
• Harsh childhood discipline
• Emotional constriction, stubbornness, indecisiveness,
fear of making mistakes, pervasive pattern of
perfectionism & inflexibility, preoccupied with rules,
regulations, orderliness, neatness, details and the
achievement of perfection, limited interpersonal skills &
relations
• DD/ OCD traits
• Course variable, unpredictable, enjoy detailed
predictable work, vulnerable to unexpected changes
(SR, major depressive dis)
• Psychotherapy (long, complex); group th/, behaviour th/
• Pharmaco th/ clomipramine, SSRI
Anxious/Avoidant
• 1-10% of gen pop
• Timid, shy, hypersensitive to rejection, criticism, lack
of self-confidence, inferioriy complex, socially
withdrawn life, avoid social/occupational activities that
involve significant interpersonal contact because of
fear of criticism, disapproval or rejection
• DD/ Schizoid, Dependent per dis
• Need protective-supportive environment
• Psychoth/ : allianceship, assertiveness training
• Pharmacoth/ : beta blockers
Dependent
• 2.5% of pers dis, F > M
• Pervasive dependency & submissiveness, lack of self-
confidence, self-doubt, pessimistic, passive, fear to
express sexual-aggressive feelings, let others make
most of the important life decisions, limited capacity to
make everyday decisions, feel helpless when alone
• DD/ Histrionic, Borderline pers dis; Agoraphobia
• Impaired occupational functioning, limited social
relations
• Psychotherapy, Behaviour th/
• Pharmacoth/: antianxiety, SSRI
Others
Narcissistic
• < 1% of gen pop
• Heightened sense of self-importance & uniqueness 
need special treatment, unable to tolerate critics,
ambitious for fame and fortune, superficial-exploitative
relationships, fragile self-esteem  depression
• DD/ Borderline, Histrionic, Antisocial pers dis
• Chronic, aging is handled poorly
• Psychotherapy
• Pharmacoth/ : lithium, SSRI
Passive-aggressive
• Covert obstructionism, procrastination, stubbornness,
resist demands for adequate performance, find
excuses for delays, inefficient, blaming others, lack of
assertiveness, needs-wishes-goals are not clear,
punitive-manipulative style of relationships, lack of
self-confidence, pessimistic
• DD/ Histrionic, Borderline, pers dis
• Mostly will have persistent psychiatric problems
(irritability, anxiety, depression, somatic complaints)
• Psychoth/ : supportive
• Pharmacoth/ : antidepressant, bzd, psychostimulant
Depressive
• M=F
• Early loss, poor parenting, punitive SE, guilt feelings
>>, abn adrenergic & serotonergic system, genetic
predisposisition
• Chronic feelings of unhappiness, self-crtitical, self-
derogatory, pessimistic, anhedonic, poor posture,
depressed facies, hoarse voice, psychomotor
retardation
• DD/ Dysthymic dis, Avoidant pers dis
• Higher rates of mood dis
• Psychoterapy (longterm)
• Pharmacoth/ : SSRI, psychostimulant
Sadomasochistic
Sadism : a desire to cause others pain by sexually
abusive or generally physically/psychologically
abusive
Masochism : achievement of sexual gratification by
inflicting (physical/psychological) pain to ownself
• A person who has the elements of both sadistic &
masochistic behaviour
• Psychotherapy
Sadistic
• Pervasive pattern of cruel, demeaning & aggressive
behaviour toward others, not motivated solely by
sexual motives
• Fascinated by violence, weapons, injury or torture
F 62 Enduring personality changes, not attributable
to brain damage and disease

Criteria, ICD 10-PPDGJ 3

Develop following catastrophic/excessive prolonged

stress or following a severe psychiatric illness, in
people with no previous personality dis  definite,
enduring change in a person’s pattern of perceiving,
relating to, or thinking about the environment and the
self  inflexible, maladaptive behaviour
After catastrophic experience
• A hostile, mistrust attitude towards the world, social
withdrawal, feelings of emptiness, hopelessness, a
chronic feeling of as if constantly threatened,
estrangement

After psychiatric illness

• Excessive dependence on and demanding attitude
towards others, conviction of being “changed”, leading
to social isolation, passivity, reduced interest (incl in
leisure activities), persistent complaints of being ill
(hypochondriacal claims), dysphoric/labile mood,
impairment in social & occupational functioning

The above manifestations must have been present for a

period of 2 years or more
F 63 Habit and impulse disorder
Criteria
ICD 10-PPDGJ 3
Uncontrollable repeated acts that have no clear rational
motivation and that generally harm the patient’s own
interests and those of other people
DSM IV
Patients do not resist impulses, drives or enticements to
do something harmful to themselves or to others

• Pt may/may not try to resist the impulses and plan

their behaviours
• Before the act : increase tension; afterward : feelings
of pleasure, satisfaction, +/- remorse, guilt
• Ego-syntonic
Etiology
Psychodynamic
• To decrease tension related to heightened instinctual
drives/diminished ego defenses
• To master anxiety, guilt, depression & other painful
affects by means of action
• Weak SE, E due to childhood deprivation
Biological
• Limbic sys abn, testosterone, temporal lobe epilepsy:
violent, aggressive and impulsive behaviour
• ADHD; abn of SE,DA,NA-ergic system
Psychosocial
• Early life events : improper model for identification
and parental figures
Types
Pathological gambling
• 1-3% of gen pop (USA), M > F
• Persistent recurrent maladaptive gambling behaviour 
preoccupation with gambling despite the consequences
(family, social, monetary, vocational, legal problems)
• Early loss (<15 yrs), inappropriate parental discipline,
exposure to gambling activity, family emphasis on
material-financial symbols, catecholamine & SE abn
• DD/ Social gambling, Manic episodes, Antisocial pers
dis
• Onset in adolescence (M) or late in life (F) : chronicity
• 3 phases of gambling : winningprogressive
lossdesperate (15 yrs)totally deteriorated (2 yrs)
• Th/ Gamblers Anonymous; hospitalization (3 mos, prep.
for psychoth/), SSRI, lithium, clomipramine
Pathological fire-setting (pyromania)
• M > F, mildly retarded, antisocial traits
• Deliberate-purposeful fire-setting on more than one
occasion due just to fascination with, interest in,
curiousity about or attraction to fire and the activities and
equipment associated with fire fighting  not related to
monetary, sociopolitical, criminal reasons or vengeance
• Sexual excitation, abn craving for power, symbol of
braveness, compensation for inferiority complex, longing
for (an absent) father
• DD/ Conduct dis, Antisocial pers dis, SR, Brain dysfunct
• Onset usually in childhood (high recurrency); if treated
prog is better than if the onset is in
adolescence/adulthood
• Th/ Incarceration : behaviour th/; children: intensive
intervention
Pathological stealing (kleptomania)
• 3.8%-24% of arrested shoplifters, F > M
• Recurrent intrusive, irresistible urges to steal
(unplanned) not needed, not valuable objects
(returned surreptitiously, discarded, hoarded)  the
act of stealing is the ultimate goal, not the object
• Losses, separations, endings of important
relationships, feelings of being neglected, unwanted,
symbolism (sexual act, aggression, oneness of
mother-child etc), brain dis, mental retardation
• DD/ Stealing, Malingering, SR
• Begin in childhood, tends to be chronic
• Psychoth/, behaviour th/, SSRI, tricyclics, ECT
Trichotillomania
• F>M
• Recurrent failure to resist impulses to pull out hairs
which can cause noticeable hair loss
• Onset related to stressful situations; disturbance of
mother-child relationships, fear of being left alone,
recent object loss, depression, self stimulation
• DD/ OCD, Factitious dis
• Generally begins in childhood/adolescence; late
onset may be associated with chronicity
• Psychoth/, behaviour th/, hypnoth/, SSRI, lithium,
anxiolytic with antihistamine properties
Others
Intermittent explosive disorder
• M>F
• Discrete episodes of losing control of aggressive
impulses which are grossly out of proportion to any
precipitating stressors, followed by sincere regret/self-
reproach
• Unfavorable childhood environment, brain damage,
decreases in serotonergic transmission
• Psychoth/, anticonvulsant, SSRI, neurosurgery (?)
Oniomania
• F>M
• Compulsive buying; low self-esteem, anxiety, reduce
stress
• Psychoth/, Debtors Anonymous, antipsychotic,
antianxiety, antidepressant, SSRI
F 64 Gender identity disorder

Gender identity is a psychological state that reflects the

self’s sense of being male or female
Assigned sex is how a person reared sexually; gender
identity is consonant with sex of rearing
Gender role is everything that people say and do
(external behavioural pattern that reflects a person’s
inner sense of gender identity) to indicate they are
male or female; usually gender identity is match with
gender role
Sex/biological sex is the anatomical & physiological
characteristics that indicate whether a person is male
or female
Sexual orientation is a person’s erotic response tendency
(object choises, erotic fantasies etc)
• A strong & persistent cross-gender identification
• Persistent discomfort about one’s assigned sex or a
sense of inappropriateness in the gender role of that
sex
• Persistent preoccupation with getting rid of their
primary & secondary sex characteristics and with
acquiring the sex characteristics of the other sex
• The wish to dress and live as a member of the other
sex
• M>F
• E/
Biological
Resting tissue is initially F; maleness & masculinity
depend on fetal & perinatal androgens
Psychosocial
Assigned sex; culturally acceptable gender roles
(learned); resolution of Oedipal complex; parenthood
problems (hostile mothering, rejected/abuse children;
absence of mother/father figures)
• Clinical features
Children : boysh girl, girly boys; claim & wish to be the
opposite sex completely
Adolescent & adult: continuation of the childhood claim
& wish, plus the desire to live & treated as the other
sex and the desire to acquire the sex characteristics
of the opposite sex (“I feel that I’m a woman trapped
in a male body” or vice versa)  ask for hormonal
th/, sex surgery
• Sexual object choice : M, F, both, neither
• Homosexuality develop in 1/3 - 2/3 of cases; < 10%
become transsexual; impaired social, occupational
functioning; depression
• Th/ role model behaviour; parental counseling;
psychoth/ (be comfortable with the desired gender
identity); hormonal treatment (changes of secondary
sex characteristics); sex reassignment surgery :
definitive  cross gender living 3 mos-1 yr &
hormonal treatment  50% still want surgery
Types
Transsexualism
A persistent desire (at least 2 yrs) to live and be accepted
as a member of the opposite sex, usually accompanied
by a sense of discomfort with one’s anatomic sex and
wish to have hormonal th/ & surgery to be as congruent
as possible with the preferred sex
Dual-role transvestism
The wearing of clothes of the opposite sex in order to
enjoy temporary experience of being the other sex, with
no desire for (permanent) sex change, also no sexual
excitement accompanies the cross-dressing
Gender identity of childhood
Persistent, intense distress about assigned sex & a desire
to be the other sex, usually first manifest during early
childhood
F 65 Disorders of sexual preference (paraphilias)
Criteria
Unusual fantasies or sexual urges or behaviours that are
recurrent and sexually arousing, and an intense urge to
act out the fantasy, occur at least 6 mos, cause
clinically significant distress/impairment in social,
occupational or other important areas of functioning
(can involve illegal activities)  a special fantasy is the
pathognomonic element; sexual arousal & orgasm are
associated phenomena
• M >>; 50% onset before age 18, peaks between 15-25
• E/ Psychosocial: Failure to complete normal
psychosexual dev; early sexual experience; modeling,
mimicking
Biological : abn hormonal levels, chromosomal
abn, soft neurological signs
• DD/ Experimental act, foreplay, brain disease
• Early onset, high frequency, no remorse/shame,
substance abuse : poor prognosis
• Th/ Individual psychoth/, group th/ behaviour th/.
antipsychotics, antidepressants, antiandrogen

Types
Exhibitionism
• M
• Recurrent urge to expose the genital to a stranger or
unsuspecting person (opposite sex); orgasm is
brought by masturbation during or after the event
• To assert masculinity : showing  fright, surprise
reaction of the spectators
Fetishism
• M
• Sexual focus are objects intimately associated with
human body (shoes, gloves, panties, bras, stockings),
sometimes with a particular texture (rubber, leather,
plastic)
• Orgasm reached by masturbation with/into the objects
or the objects incorporated into sexual intercourse
• The objects are symbol of phallus, associated with
sexual stimulation at an early age
Transvestic fetishism
• Fantasies & sexual urges to wear the opposite sex
clothing for arousal & adjunct to masturbation/coitus
• M > F ; begins in childhood/early adolescence, cross-
dressing may become permanent; overt symptoms :
since latency, mostly at pubescence/adolescence
Voyeurism (scopophilia)
• Recurrent preoccupation with fantasies and acts to
look at people who are naked or engaging in grooming
or sexual activity (without the observed people being
aware), usually followed with masturbation to orgasm
• Mostly M, first act usually during childhood
Paedophilia
• Recurrent, intense sexual urges toward/arousal by
prepubertal/early pubertal children, for at least 6 mos
(the perpetrator aged 16 yrs/more, at least 5 yrs older
than the victim); mostly M
• Genital fondling, oral sex
• 95% perpetrators are heterosexual, 60% victims are
boys; some perpetrators are interested only to girls,
some to boys and some in both sexes
Sadomasochism
• A preference for sexual activity that involves
bondage, infliction of pain or humiliation; M > F
• Prefer to be the recipient : masochism  childhood
experience, that pain is a prerequisite for pleasure
• Prefer to be the provider : sadism  defense against
fears of castration
• Contributory causes : hereditary predisposition,
hormonal malfunctioning, pathological relationships, a
history of sexual abuse, having other mental illness
Others
Frotteurism
• M, passive, isolated
• Penis (hands) rubbed against the buttocks or other
part of a fully cloth woman to achieve orgasm
Telephone and computer scatologia
• M ; obscene phone calling to unsuspecting person +
masturbation
Necrophilia
• Obsession of obtaining sexual gratification from
corpses  inflicting the greatest humiliation to the
lifeless victims: psychosis ?
Partialism, oralism
• Oral sex is the only source of sexual gratification;
no coitus
Zoophilia
• Animals are preferentially incorporated into arousal
fantasies or sexual activities
Coprophilia & Klismaphilia
• Attraction to sexual pleasure associated with the
desire to defecate on a partner, to be defecated on,
or to eat feces (coprophagia) or compulsive utterance
of obscene words (coprolalia)
• Use of enemas as part of sexual stimulation 
fixation at anal stage
Urophilia
• Interest in sexual pleasure associated with the desire
to urinate on a partner or to be urinated on; may be
associated with masturbatory technique (insertion of
foreign objects into the urethra for sexual stimulation)
Masturbation
• Achieving sexual pleasure-orgasm by ownself is
prefered than sex with a partner

Hypoxyphilia
• Desire to achieve an altered state of consciousness
due to hypoxia while experiencing orgasm
F 66 Psychological and behavioural disorders
associated with sexual development and
orientation

Sexual maturation disorder

Uncertainity about gender identity/sexual orientation 
anxiety, depression

Egodystonic sexual orientation

• Dissatisfaction with sexual (homosexual) arousal
pattern
 a desire to increase heterosexual arousal
 strong negative feelings of being homosexual
• Sexual reorientation (psychoth/ behaviour th/), or be a
happy homosexual
F 68 Other disorders of adult personality and
behaviour
Elaboration of physical symptoms for psychological
reasons (Compensation neurosis)

• Elaboration of physical symptoms for psychological

reasons
• Physical symptoms due to a confirmed physical
disorder /disease/disability become
exaggerated/prolonged  dissatisfaction with the
result of treatment, disappointment with the personal
attention received in wards/clinics, possibility of
financial compensation
Intentional production or feigning of symptoms or
disabilities, either physical or psychological
(Factitious disorder, Munchhausen’s syndrome
• Characterized by physical (cuts, abrasion, self injection
of toxic substance etc) or psychological symptoms that
are intentionally produced or feigned to assume the sick
role
• No external incentive; hospitalization is the primary
objective
• M > F; 9% among hospitalized patient
• Childhood abuse, deprivation  frequent hospitalization
 hospitalization is an escape from traumatic home
situation and a place to find loving, caring caretakers
• DD/ Malingering : intentional production or feigning of
physical/psychological symptoms/disabilities for certain
incentive (monetary)