Personality disorders

Presented by: Araya M (FMR)

Moderated by : Dr. Meseret, Family medicine
specialist

November, 3, 2021
 Outline
• Objectives
• Introduction
• Definitions
• Classification
• Etiologies
• Clinical diagnosis and discussions
• Management
• Summary
 Objectives
By the end of this presentation everyone will be able to
• Define Personality trait and Disorders
• List clusters of personality disorder
• Describe Cluster A personality disorders
• Describe Cluster B personality disorders
• Describe Cluster C personality disorders
• Describe other specified personality disorders and
personality changes due to a general medical
condition
 Introduction
• Personality (trait) refers to all of the
characteristics that adapt in unique ways to
ever-changing internal and external
environments.
• Are flexible
 Definition
• Personality disorder as an enduring pattern of
behavior and inner experiences that deviates
significantly from the individual's cultural
standards; is rigidly pervasive; has an onset in
adolescence or early adulthood; is stable
through time; leads to unhappiness and
impairment; and manifests in at least two of
the following four areas: cognition, affectivity,
interpersonal function, or impulse control.
• Occur in 10 to 20 percent of the general
population
• 50 percent of all psychiatric patients have a
personality disorder,
• Personality disorder is also a predisposing factor
for other psychiatric disorders (e.g., substance
use, suicide, affective disorders, impulse-control
disorders, eating disorders, and anxiety
disorders) in which it interferes with treatment
outcomes of many clinical syndromes and
increases personal incapacitation, morbidity, and
mortality of these patients.
• Likely to refuse psychiatric help and to deny their
problems than persons with anxiety disorders,
depressive disorders, or obsessive compulsive
disorder.
• Personality disorder symptoms are ego syntonic (i.e.,
acceptable to the ego, as opposed to ego dystonic)
and alloplastic (i.e., adapt by trying to alter the
external environment rather than themselves).
• Do not feel anxiety about their maladaptive behavior.
 CLASSIFICATION
• Based on descriptive similarities there are
three classes of clusters
• Cluster A
• Cluster B
• Cluster C
 Cluster A
Disorders with odd, aloof features
• Paranoid
• Schizoid
• Schizotypal
 Cluster B
Disorders with dramatic, impulsive, and erratic
features
• Borderline,
• Antisocial,
• Narcissistic, and
• Histrionic
 Cluster C
Disorders sharing anxious and fearful features
• Avoidant
• Dependent
• Obsessive-compulsive
 ETIOLOGY
• Cluster A personality disorders are more
common in the biological relatives of patients
with schizophrenia
• Obsessive-compulsive traits are more common
in monozygotic twins than in dizygotic twins,
• Antisocial personality disorder is associated with
alcohol use disorders.
• Patients with avoidant personality disorder often
have high anxiety levels.
• Hormones
• Psychoanalytic Factors
 PARANOID PERSONALITY DISORDER
• Long-standing suspiciousness and mistrust of
persons in general.
• Refuse responsibility for their own feelings
and assign responsibility to others.
• Are often hostile, irritable, and angry.
• 2 to 4 percent of the general population.
 Diagnosis
• Patients with paranoid personality disorder may be
formal in manner and act baffled about having to
seek psychiatric help.
• Muscular tension, an inability to relax, and a need to
scan the environment for clues may be evident, and
the patient's manner is often humorless and
serious.
• Their speech is goal directed and logical.
• Their thought content shows evidence of projection,
prejudice, and occasional ideas of reference.
 Diagnostic Criteria
A pervasive distrust and suspiciousness of others such
that their motives are interpreted as malevolent,
beginning by early adulthood and present in a variety of
contexts, as indicated by four (or more) of the following:
1. Suspects, without sufficient basis, that others are
exploiting, harming, or deceiving him or her.
2. Is preoccupied with unjustified doubts about the loyalty
or trustworthiness of friends or associates.
3. Is reluctant to confide in others because of unwarranted
fear that the information will be used maliciously against
him or her.
4. Reads hidden demeaning or threatening
meanings into benign remarks or events.
5. Persistently bears grudges (i.e., is unforgiving
of insults, injuries, or slights).
6. Perceives attacks on his or her character or
reputation that are not apparent to others and is
quick to react angrily or to counterattack.
7. Has recurrent suspicions, without justification,
regarding fidelity of spouse or sexual partner.
B. Does not occur exclusively during the course of
schizophrenia, a bipolar disorder or depressive
disorder with psychotic features, or another
psychotic disorder and is not attributable to the
physiological effects of another medical condition.

Note: If criteria are met prior to the onset of

schizophrenia, add "premorbid," i.e., "paranoid
personality disorder (premorbid)."
• Those with the disorder expect to be exploited or
harmed by others in some way.
• Persons with this disorder externalize their own
emotions and use the defense of projection; they
attribute to others the impulses and thoughts that
they cannot accept in themselves
• Affectively restricted and appear to be
unemotional.
• They lack warmth and are impressed with, and pay
close attention to, power and rank.
• They express disdain for those they see as
weak, sickly, impaired, or in some way
defective. In social situations, persons with
paranoid personality disorder may appear
business-like and efficient, but they often
generate fear or conflict in others.
 Differential Diagnosis
• Delusional disorder
• Schizophrenia
• Borderline personality
• Antisocial character.
• Schizoid personality disorder
 Treatment
• Psychotherapy
• Therapists should be straightforward in all their
dealings with these patients.
• If a therapist is accused of inconsistency or a fault,
such as lateness for an appointment, honesty and
an apology are preferable to a defensive
explanation.
• Therapists must remember that trust and toleration
of intimacy are troubled areas for patients with this
disorder.
• Pharmacotherapy.
• Useful in dealing with agitation and anxiety. In
most cases, an antianxiety agent such as
diazepam suffices.
• It may be necessary, however, to use an
antipsychotic such as haloperidol in small
dosages and for brief periods to manage
severe agitation
SCHIZOID PERSONALITY DISORDER
• Characterized by a lifelong pattern of social
withdrawal.
• Persons with schizoid personality disorder are often
seen by others as eccentric, isolated, or lonely.
• Their discomfort with human interaction; their
introversion; and their bland, constricted affect are
noteworthy.
• May affect 5 percent of the general population.
 Diagnosis
• They rarely tolerate eye contact
• Patients are eager for the interview to end.
• Their affect may be constricted, aloof, or
inappropriately serious, but underneath the
aloofness, sensitive clinicians can recognize
fear.
• They are likely to give short answers to
questions and to avoid spontaneous
conversation.
• They appear quiet, distant, seclusive, and
unsociable.
• Persons with schizoid personality disorder usually
reveal a lifelong inability to express anger directly.
• They can invest enormous affective energy in
nonhuman interests, such as mathematics and
astronomy, and they may be very attached to
animals.
 DSM-5 Diagnostic Criteria
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:
1 . Neither desires nor enjoys close relationships,
including being part of a family.
2 . Almost always chooses solitary activities.
3 . Has little, if any, interest in having sexual
experiences with another person.
4. Takes pleasure in few, if any, activities.
5 . Lacks close friends or confidants other than
first-degree relatives.
6. Appears indifferent to the praise or criticism
of others.
7. Shows emotional coldness, detachment, or
flattened affectivity.
B. Does not occur exclusively during the course of
schizophrenia, a bipolar disorder or depressive disorder
with psychotic features, another psychotic disorder, or
autism spectrum disorder and is not attributable to the
physiological effects of another medical condition.

Note: If criteria are met prior to the onset of

schizophrenia, add "premorbid," i.e., "schizoid
personality disorder (premorbid)."
 Differential Diagnosis
• Schizophrenia, delusional disorder, and
affective disorder with psychotic features
• Paranoid personality disorder
• Obsessive compulsive and avoidant
personality disorders
• Schizotypal personality
• Autistic disorder and Asperger's syndrome
 Treatment
Psychotherapy.
• The treatment of patients with schizoid personality
disorder is similar to that of those with paranoid
personality disorder.
Pharmacotherapy.
• Small dosages of antipsychotics, antidepressants, and
psychostimulants has benefitted some patients.
• Benzodiazepines may help diminish interpersonal anxiety.
• Serotonergic agents may make patients less sensitive to
rejection
 SCHIZOTYPAL PERSONALITY DISORDER
• Are 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 percent of the population.
• Increased prevalence in the families of
schizophrenic patients
 Diagnosis
• On the basis of the patients' peculiarities of thinking,
behavior, and appearance.
• Taking a history may be difficult because of the patients
unusual way of communicating.
• Patients may be superstitious and may believe that
they have other special powers of thought and insight.
• Because persons with schizotypal personality disorder
have poor interpersonal relationships and may act
inappropriately, they are isolated and have few friends.
 DSM-5 Diagnostic Criteria
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:
1 . Ideas of reference (excluding delusions of reference).
2 . 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).
3 . Unusual perceptual experiences, including bodily illusions.
4. Odd thinking or speech (e.g., vague, circumstantial,
metaphorical, overelaborate, or stereotyped).
5. Suspiciousness or paranoid ideation.
6. Inappropriate or constricted affect.
7. Behavior or appearance that is odd, eccentric, or
peculiar.
8. Lack of close friends or confidants other than first
degree relatives.
9. Excessive social anxiety that does not diminish with
familiarity and tends to be associated with paranoid
fears rather than negative judgments about self.
B. Does not occur exclusively during the course
of schizophrenia, a bipolar disorder or
depressive disorder with psychotic features,
another psychotic disorder, or autism spectrum
disorder.

Note: If criteria are met prior to the onset of

schizophrenia, add "premorbid," i.e.,
"schizotypal personality disorder (premorbid)."
 Differential Diagnosis
• Schizoid and avoidant personality disorders
• Schizophrenia
• Some patients meet the criteria for both
schizotypal personality disorder and
borderline personality disorder.
• Paranoid personality disorder
• According to current clinical thinking, the
schizotypal 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.
• 10 percent of those with schizotypal personality
disorder eventually committed suicide
 Treatment
Psychotherapy.
• The principles of treatment of schizotypal personality
disorder do not differ from those of schizoid
personality disorder, but clinicians must deal
sensitively with the former.
• These patients have peculiar patterns of thinking, and
some are involved in cults, strange religious practices
• Therapists must not ridicule such activities or be
judgmental about these beliefs or activities.
Pharmacotherapy.
• Antipsychotic medication may be useful in
dealing with ideas of reference, illusions, and
other symptoms of the disorder and can be
used in conjunction with psychotherapy.
• Antidepressants are useful when a depressive
component of the personality is present.
 ANTISOCIAL PERSONALITY DISORDER
• Inability to conform to the social norms that
ordinarily govern many aspects of a person's
adolescent and adult behavior.
• Characterized by continual antisocial or criminal
acts, the disorder is not synonymous with
criminality.
• Between 0.2 and 3 percent according to DSM-5
• The highest prevalence of antisocial personality
disorder is found among the most severe samples of
men with alcohol use disorder (over 70 percent) and in
prison populations, where the prevalence may be as
high as 75 percent.
• It is much more common in males than in female
• The onset of the disorder is before the age of 15 years.
• Five times more common among first-degree relatives
of men with the disorder than
among control participants.
 Diagnosis
• Patients can appear composed and credible,
• Their stories however reveal many areas of
disordered life functioning.
• Lying, truancy, running away from home,
thefts, fights, substance abuse, and illegal
activities are typical experiences that patients
report as beginning in childhood.
• Highly representative of so-called con men.
• Extremely manipulative and can frequently talk
others into participating in schemes for easy ways
to make money or to achieve fame or notoriety.
• Lack of remorse for these actions
• Diagnosis of antisocial personality disorder is not
warranted when intellectual disability,
schizophrenia, or mania can explain the
symptoms
 DSM-5 Diagnostic Criteria
A pervasive pattern of disregard for and violation of
the rights of others, occurring since age 1 5 years, as
indicated by three (or more) of the following:
1 . Failure to conform to social norms with respect to
lawful behaviors, as indicated by repeatedly
performing acts that are grounds for arrest.
2 . Deceitfulness, as indicated by repeated lying, use
of aliases, or conning others for personal profit or
pleasure.
3 . Impulsivity or failure to plan ahead.
4. Irritability and aggressiveness, as indicated by
repeated physical fights or assaults.
5 . Reckless disregard for safety of self or others.
6. Consistent irresponsibility, as indicated by
repeated failure to sustain consistent work
behavior or honor financial obligations.
7. Lack of remorse, as indicated by being
indifferent to or rationalizing having hurt,
mistreated, or stolen from another.
B. The individual is at least age 18 years.
C. There is evidence of conduct disorder with
onset before age 1 5 years.
D. The occurrence of antisocial behavior is not
exclusively during the course of schizophrenia or
bipolar disorder
 Treatment
Psychotherapy.
• If patients with antisocial personality disorder are
immobilized (e.g., placed in hospitals), they often
become amenable to psychotherapy.
• When patients feel that they are among peers, their
lack of motivation for change disappears.
• Self-help groups have been more useful than jails in
alleviating the disorder. Therapists must find ways of
dealing with patients' self-destructive behavior.
• To overcome patients' fear of intimacy,
therapists must frustrate patients' desire to
run from honest human encounters.
• In doing so, therapists face the challenge of
separating control from punishment and of
separating help and confrontation from social
isolation and retribution
Pharmacotherapy.
• Used to deal with incapacitating symptoms such as anxiety,
rage, and depression, but because patients are often
substance abusers, drugs must be used carefully.
• If a patient shows evidence of attention-deficit/hyperactivity
disorder, psychostimulants such as methylphenidate may be
useful.
• Attempts have been made to alter catecholamine metabolism
with drugs and to control impulsive behavior with antiepileptic
drugs, for example, carbamazepine or valproate especially if
abnormal waveforms are noted on an EEG.
 BORDERLINE PERSONALITY DISORDER
• Characterized by extraordinarily unstable
affect, mood, behavior, object relations, and
self-image.
• “Emotionally unstable personality disorder”
ICD-10
• In about 1 to 2 percent of the population
• Twice as common in women as in men.
 Diagnosis
• The behavior of patients with borderline
personality disorder is highly unpredictable
• Self-mutilations to elicit help from others, to
express anger, or to numb themselves to
overwhelming affect.
• They feel both dependent and hostile
• Cannot tolerate being alone
• Complain about chronic feelings of emptiness
and boredom and the lack of a consistent
sense of identity (identity diffusion)
• Intolerable aspects of the self are projected
• Splitting
• Shifts of allegiance from one person or group
to another are frequent.
 DSM-5 Diagnostic Criteria
A pervasive pattern of instability of interpersonal relationships, self-image,
and affects, and marked impulsivity, beginning by early adulthood and
present in a variety of contexts, as indicated by five (or more) of the
following:
1 . Frantic efforts to avoid real or imagined abandonment. (Note: Do not
include suicidal or self-mutilating behavior covered in Criterion 5).
2. A pattern of unstable and intense interpersonal relationships
characterized by alternating between extremes of idealization and
devaluation.
3 . Identity disturbance: markedly and persistently unstable self-image or
sense of self.
4. impulsivity in at least two areas that are potentially self damaging (e.g.,
spending, sex, substance abuse, reckless driving, binge eating). (Note: Do
not include suicidal or self-mutilating behavior covered in Criterion 5.)
5. Recurrent suicidal behavior, gestures, or threats, or self-
mutilating behavior.
6. Affective instability due to a marked reactivity of mood
(e.g., intense episodic dysphoria, irritability, or anxiety usually
lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger
(e.g., frequent displays of temper, constant anger, recurrent
physical fights).
9. Transient, stress-related paranoid ideation or severe
dissociative symptoms
 Differential Diagnosis
• Schizophrenia
• Schizotypal personality disorder
• Paranoid personality disorder
 Treatment
Psychotherapy
• The treatment of choice
• Behavior therapy to control patients'
impulses and angry outbursts and to reduce
their sensitivity to criticism and rejection.
• Social skills training, especially with videotape
playback, helps enable patients to see how
their actions affect others and thereby improve
their interpersonal behavior.
• Within the protected environment of the
hospital, patients who are excessively impulsive,
self-destructive, or self mutilating can be given
limits, and their actions can be observed
• DIALECTICAL BEHAVIOR THERAPY.
• MENTALIZATION-BASED TREATMENT(they learn
to better regulate their thoughts and feelings)
• TRANSFERENCE-FOCUSED PSYCHOTHERAPY
Pharmacotherapy
• Antipsychotics have been used to control anger, hostility,
and brief psychotic episodes.
• Antidepressants improve the depressed mood common in
patients with borderline personality disorder.
• The MAO inhibitors (MAOis) have successfully modulated
impulsive behavior in some patients.
• Benzodiazepines help anxiety and depression
• Anticonvulsants, such as carbamazepine, may improve
global functioning for some patients.
• Serotonergic agents such as selective serotonin reuptake
inhibitors (SSRis) have been helpful in some cases.
 HISTRIONIC PERSONALITY DISORDER
• Are excitable and emotional and behave in a
colorful, dramatic, extroverted fashion.
• Accompanying their flamboyant aspects,
however, is often an inability to maintain
deep, long-lasting attachments.
• 10 to 15 percent
• More frequently in women than in men.
 Diagnosis
• Are generally cooperative and eager to give a detailed
history.
• Gestures and dramatic punctuation in their
conversations are common; they may make frequent
slips of the tongue, and their
language is colorful.
• The results of the cognitive examination are usually
normal, although a lack of perseverance may be shown
on arithmetic or concentration tasks, and the patients'
forgetfulness of affect-laden material may be
astonishing.
• Show a high degree of attention-seeking
behavior.
• They tend to exaggerate their thoughts and
feelings and make everything sound more
important than it really is.
• They display temper tantrums, tears, and
accusations when they are not the center of
attention or are not receiving praise or
approval
• Seductive behavior is common in both sexes.
• Sexual fantasies about persons with whom patients are
involved are common
• Flirtatious rather than sexually aggressive. In fact, histrionic
patients may have a psychosexual dysfunction; women
may be anorgasmic, and men may be impotent.
• Their relationships tend to be superficial.
• Their strong dependence needs make them overly trusting
and gullible.
• The major defenses of patients with histrionic personality
disorder are repression and dissociation.
 DSM-5 Diagnostic Criteria
A pervasive pattern of excessive emotionality and attention
seeking, beginning in early adulthood and present in a variety
of contexts, as indicated by five (or more) of the following:
1 . Is uncomfortable in situations in which he or she is not the
center of attention.
2. Interaction with others is often characterized by
inappropriate sexually seductive or provocative behavior.
3. Displays rapidly shifting and shallow expression of
emotions.
4. Consistently uses physical appearance to draw attention to
self.
5 . Has a style of speech that is excessively
impressionistic and lacking in detail.
6. Shows self-dramatization, theatricality, and
exaggerated expression of emotion.
7. Is suggestible (i.e., easily influenced by others
or circumstances).
8. Considers relationships to be more intimate
than they actually are
 Differential Diagnosis
• Borderline personality disorder
• Brief psychotic disorder
• Dissociative disorders
 Treatment
• Psychotherapy. Patients with histrionic
personality disorder are often unaware of
their own real feelings; clarification of their
inner feelings is an important therapeutic
process. Psychoanalytically oriented
psychotherapy, whether group or individual, is
probably the treatment of choice for histrionic
personality disorder
Pharmacotherapy.
• Can be adjunctive when symptoms are
targeted (e.g., the use of antidepressants
for depression and somatic complaints,
antianxiety agents for anxiety, and
antipsychotics for derealization and illusions).
 NARCISSISTIC PERSONALITY DISORDER

• Characterized by a heightened sense of self-

importance, lack of empathy, and grandiose
feelings of uniqueness.
• Underneath, however, their self-esteem is
fragile and vulnerable to even minor criticism.
• Range from less than 1 to 6 percent
 Diagnosis
• A grandiose sense of self-importance
• Sense of entitlement
• Handle criticism poorly
• Interpersonal exploitiveness is common
• Cannot show empathy, and they feign
sympathy only to achieve their own selfish
ends.
• Susceptible to depression.
 DSM-5 Diagnostic Criteria
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:
1 . Has a grandiose sense of self-importance (e.g., exaggerates
achievements and talents, expects to be recognized as superior
without commensurate achievements).
2 . Is preoccupied with fantasies of unlimited success, power,
brilliance, beauty, or ideal love.
3 . Believes that he or she is "special" and unique and can only be
understood by, or should associate with, other special or high-
status people (or institutions).
4. Requires excessive admiration.
5 . Has a sense of entitlement (i.e., unreasonable
expectations of especially favorable treatment or
automatic compliance with his or her expectations).
6. Is interpersonally exploitative (i.e., takes advantage
of others to achieve his or her own ends).
7. Lacks empathy: is unwilling to recognize or identify
with the feelings and needs of others.
8. Is often envious of others or believes that others
are envious of him or her.
9. Shows arrogant, haughty behaviors or attitudes.
 Differential Diagnosis
• Borderline, histrionic, and antisocial
personality disorders often accompany
narcissistic personality disorder
 Treatment
• Psychotherapy. Because patients must renounce
their narcissism to make progress, the treatment
of narcissistic personality disorder is difficult.
• Some have advocated using psychoanalytic
approaches to effect change
• Some clinicians advocate group therapy for their
patients so they can learn how to share with
others and , can develop an empathic response
to others
Pharmacotherapy.
• Lithium has been used with patients whose
clinical picture includes mood swings.
• Because patients with narcissistic personality
disorder tolerate rejection poorly and are
susceptible to depression, antidepressants,
especially serotonergic drugs, may also be of
use
 AVOIDANT PERSONALITY DISORDER
• Show extreme sensitivity to rejection and may
lead socially withdrawn lives.
• They are not asocial and show a great desire
for companionship, but they need unusually
strong guarantees of uncritical acceptance.
• Commonly described as having an inferiority
complex.
• 2 to 3 percent of the general population
 Diagnosis
• Most striking aspect is anxiety about talking
with an interviewer.
• Their nervous and tense manner appears to wax
and wane with their perception of whether an
interviewer likes them.
• They seem vulnerable to the interviewer's
comments and suggestions and may regard a
clarification or interpretation as criticism
• Hypersensitivity to rejection
• They are afraid to speak up in public
• Apt to misinterpret other persons' comments as
derogatory or ridiculing.
• The refusal of any request leads them to
withdraw from others and to feel hurt.
• They rarely attain much personal advancement
or exercise much authority but seem shy and
eager to please.
 DSM-5 Diagnostic Criteria
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
• Dependent personality disorder
 Treatment
Psychotherapy.
• Solidifying an alliance with patients.
• As trust develops, a therapist must convey an
accepting attitude toward the patient's
fears, especially the fear of rejection.
• The therapist eventually encourages a patient to
move out into the world to take what are
perceived as great risks of humiliation, rejection,
and failure.
• Cautious when giving assignments to exercise
new social skills outside therapy; failure can
reinforce a patient's already poor self-esteem.
• Group therapy may help patients understand
how their sensitivity to rejection affects them
and others.
• Assertiveness training is a form of behavior
therapy that may teach patients to express their
needs openly and to enlarge their self-esteem.
Pharmacotherapy
• Some patients are helped by B-adrenergic receptor
antagonists, such as atenolol to manage autonomic
nervous system hyperactivity, which tends to be
high in patients with avoidant personality disorder,
especially when they approach feared situations.
• Serotonergic agents may help rejection sensitivity.
 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
• More common in women
• DSM-5 reports an estimated prevalence of 0.6
percent
 Diagnosis
• Patients appear compliant.
• They try to cooperate , welcome specific
questions, and look for guidance
• Cannot make decisions without an excessive
amount of advice and reassurance from others
• anxious if asked to assume a leadership role
• Need to be attached to another
person. Folie a deux (shared psychotic disorder)
• Pessimism, self-doubt, passivity, and fears of
expressing sexual and aggressive feelings all
typify the behavior of persons with dependent
personality disorder.
• An abusive, unfaithful, or alcoholic spouse
may be tolerated for long periods to avoid
disturbing the sense of attachment
 DSM-5 Diagnostic Criteria
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 or
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 and borderline personality disorders
• Schizoid and schizotypal personality disorders
• Agoraphobia
 Treatment
Psychotherapy.
• The treatment of dependent personality disorder is
often successful.
• Insight-oriented therapies enable patients to
understand the antecedents of their behavior, and
with the support of a therapist, patients can become
more independent, assertive, and self-reliant.
• Behavioral therapy, assertiveness training, family
therapy, and group therapy have all been used, with
successful outcomes in many cases.
• A problem may arise in treatment when a
therapist encourages a patient to change the
dynamics of a pathological relationship
• May become anxious and unable
to cooperate in therapy; they may feel tom
between complying with the therapist and
losing a pathological external relationship
Pharmacotherapy.
• Pharmacotherapy has been used to deal with specific
symptoms, such as anxiety and depression,
which are common associated features of dependent
personality disorder.
• Patients who experience panic attacks or who have
high levels of separation anxiety may be helped by
imipramine
• Benzodiazepines and serotonergic agents have also
been useful.
 OBSESSIVE-COMPULSIVE PERSONALITY
DISORDER
• Characterized by emotional constriction,
orderliness, perseverance, stubbornness,
and indecisiveness.
• The essential feature of the disorder is a
pervasive pattern of perfectionism and
inflexibility.
• 2 to 8 percent
• More common in men
• More frequently in first-degree biological
relatives of persons with the disorder
• Backgrounds characterized by harsh discipline
• Freud hypothesized that the disorder is
associated with difficulties in the anal stage of
psychosexual development, generally around
the age of 2 years,
 Diagnosis
• May have a stiff, formal, and rigid demeanor
• Their affect is not blunted or flat but can be
described as constricted.
• They lack spontaneity, and their mood is usually
serious.
• Such patients may be anxious about not being in
control of the interview.
• Rationalization, isolation, intellectualization,
reaction formation, and undoing are defense
mechanisms
 DSM-5 Diagnostic Criteria
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 over conscientious, 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
• Obsessive-compulsive disorder
• Obsessive-compulsive traits
 Treatment
Psychotherapy
• Are often aware of their suffering, and they seek
treatment on their own
• Group therapy and behavior therapy occasionally
offer certain advantages.
• Preventing the completion of their habitual
behavior raises patients' anxiety and leaves them
susceptible to learning new coping strategies.
Patients can also receive direct rewards for change
in group therapy
• Clomipramine and such serotonergic agents as
fluoxetine, usually at dosages of 60 to 80 mg a
day, may be useful if obsessive compulsive
signs and symptoms break through.
OTHER SPECIFIED PERSONALITY DISORDER

• Reserved for disorders that do not fit into any

of the personality disorder categories
described above.
• Passive-aggressive personality, depressive
personality, oppositionalism, sadism, or
masochism are included
PERSONALITY CHANGE DUE TO A GENERAL
MEDICAL CON DITION
• ICD-10 includes the category personality and
behavioral disorders due to brain disease, damage,
and dysfunction
• Organic personality disorder, post encephalitic
syndrome, and postconcussional syndrome.
• Characterized by a marked change in personality
style and traits from a previous level of functioning.
• Patients must show evidence of a causative organic
factor antedating the onset of the personality
change.
 Summary
• Personality traits and personality disorders are
different entities and sometimes
differentiating might be difficult
• Functionality is affected
• Superimposed mental illness is very common
• Psychotherapy is the first line therapy
• Therapy often takes years
THANK YOU
QUESTIONS?
 References
• Kaplan and Sadocks synopsis of psychiatry ,
11th Edition
• Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition
• World wide web