Normal Personality Development and Personality Disorders

1. Normal Personality Development and Personality Disorders Janet E. Johnson, MD, MPH Tulane University School of Medicine Department of Psychiatry and Behavioral Sciences

2. Objectives At the conclusion of this learning module, the student should be able: • Be familiar with personality development List the personality disorders included in DSM-IV-TR • List the major diagnostic criteria for each and be familiar with general characteristics of each disorder, including epidemiology • Discuss the differential diagnosis for each disorder • Be familiar with contributing biological theories and genetics for personality disorders

3. Personality • Defined as the totality of emotional and behavioral traits that characterize the person in day-to-day living under ordinary conditions. • Usual manner of thinking, feeling, behaving and relating to others • Relatively stable and predictable. • Blend of inborn temperament, genetic strengths and vulnerabilities, and impact of positive and negative life experiences.

4. Normal Personality Development • Second half of 1st year: attachment • Internalization: mechanism for building psychological structure • Stable pattern of a child’s temperament becomes established during second year. • Nature versus nurture? • Behavioral genetics revealing pervasive genetic influences on normal and abnormal personality.

5. What is Normal? • Who’s to say? • Circumstances, culture/sub-culture, setting/location, timing, age

6. Who’s Normal?

7. Who’s Normal?

8. Personality assessment • Meyers-Brigg • Five Factor Model • Cloninger’s Seven-Factor Model • Biogenic Spectrum Model

9. Myers Brigg • Questionnaire designed to measure psychological preferences in how people perceive the world and make decisions. • Widely utilized • Extrapolated from Jung’s theories. • Two pairs of cognitive functions: • Rational functions: thinking and feeling • Irrational functions: sensing and intuition

10. Dichotomies • Extraversion (E) – (I) Introversion • Sensing (S) – (N) Intuition • Thinking (T) – (F) Feeling • Judgment (J) – (P) Perception • 16 possible types • Example: ESTJ

11. Five Factor Model • Neuroticism (anxiety, depression, vulnerability, hostility) • Extraversion (warmth, assertiveness, activity, gregariousness) • Openness (feelings, fantasy, ideas, values) • Agreeableness (trust, altruism, modesty) • Conscientiousness (dutifulness, self- discipline, deliberation)

12. Seven-Factor Model of Temperament and Character • Harm avoidance • Reward dependence • Novelty seeking • Persistence • Character factor • Self-directedness • Cooperativeness • Self-transcendence

13. Temperament Factors(harm avoidance, reward dependence, novelty seeking, persistence • Independently heritable • Manifested early in life • Involved in perceptual memory and habit formation • Associated with biologic features • Novelty seeking  decreased dopaminergic activity • Harm Avoidance -> high serotonergic activity • Reward dependence  low noradrenergic activity

14. Personality Disorders • A personality disorder is a variant of those character traits that goes beyond the range found in most people. • When personality traits are inflexible and maladaptive and cause either significant functional impairment or subjective distress they constitute a class of personality disorder. • Patients with personality disorders show deeply ingrained, inflexible, and maladaptive patterns of relating to and perceiving both the environment and themselves

15. General Diagnostic Criteria • An enduring pattern of inner experience and behavior that deviates markedly from the expectation of the individual’s culture. The pattern is manifested in two or more of the following areas: • Cognition (perceiving and interpreting self, other people and events) • Affectivity (range, intensity, lability appropriateness of emotional response) • Interpersonal functioning • Impulse control

16. General Diagnostic Criteria • The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. • The enduring pattern leads to clinically significant distress or impairment in social, occupational or other important areas of functioning. • The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. • The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. • The enduring pattern is not due to the direct effects of a substance or a general medical condition.

17. Personality Disorders • More likely to refuse psychiatric help than other psychiatric disorders • Ego-syntonic • Regarded as unmotivated for treatment • Grouped into three clusters: A, B, C • Other: Not otherwise specified and mixed • Diagnosed on Axis II • Elevated rates of divorce, unemployment, homelessness, perpetration of child abuse, child custody proceedings, separation

18. Personality Disorders • Common in general population • Prevalence of 10-18% • Outpatient 30-50% • Inpatient > 50% co-morbidity • Males and females equal overall • Etiology • Genetics • Psychoanalytic theories • Freud: psychosexual development • Reich: defense mechanisms

19. Common Defense Mechanisms • Projection • Splitting • Regression • Fantasy • Dissociation • Intellectualization • Isolation • Reaction formation • Repression • Acting out • Passive aggression

20. Cluster A: Paranoid, Schizoid, Schizotypal • Odd, eccentric (“weird”) • Key clinical features: social deficits, absence of close relationships • Treatment: structure, rehabilitation, support, medication • Course: stable • Prognosis: poor • Genetics: • More common in the biological relatives of schizophrenic patients than among control groups.

21. Paranoid Personality Disorder • 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:

22. Paranoid Diagnostic Criteria • 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/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.

23. Paranoid Diagnostic Criteria • 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. • 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.

24. Paranoid Personality Disorder • Characterized by long-standing suspiciousness and mistrust of people in general. • Refuse responsibility for their own feelings; are often angry, hostile, irritable. • Bigot, injustice collector, pathologically jealous spouse, litigious crank • Prevalence 0.5-2.5 % • Male > female • Differential diagnosis: schizotypal pd, schizophrenia, delusional d/o • Antipsychotic meds sometimes useful

25. 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: Schizoid Personality Disorder

26. Schizoid Diagnostic Criteria • 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 confidents other than first-degree relatives. • Appears indifferent to the praise or criticism of others. • Shows emotional coldness, detachment, or flattened affectivity.

27. Schizoid Personality Disorder • 1-7.5% of population • Males diagnosed 2x females • Intact reality testing • Most function relatively well, generally do not require clinical intervention • Psychotherapy treatment of choice (supportive), but rarely seek treatment • Differential diagnosis: schizotypal pd, avoidant pd

28. Schizotypal Personality Disorder • 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:

29. Schizotypal Diagnostic Criteria • Indicated by five or more of the following: • Ideas of reference. • Odd beliefs or magical thinking that influences behavior and is inconsistent with sub-cultural norms (superstitiousness, clairvoyance, telepathy). • Unusual perceptual experiences, including bodily illusions. • Odd thinking and speech (vague, metaphorical, stereotyped, circumstantial). • Suspiciousness or paranoid ideation. • Inappropriate or constricted affect. • Behavior or appearance that is odd, eccentric or peculiar.

30. Schizotypal Personality Disorder • 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. • Does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, another psychotic disorder or a pervasive developmental disorder.

31. Schizotypal Personality Disorder • Schizophrenia spectrum disorder • Some forms involve biologic abnormalities characteristic of schizophrenia • Prevalence: 3% of population • Males > females • Approximately 10% commit suicide • Differential diagnosis: schizophrenia, paranoid pd, schizoid pd, avoidant pd • Low dose antipsychotics may be helpful

32. CLUSTER B: Antisocial, Borderline, Narcissistic, Histrionic • B for “bad” • Dramatic, emotional, erratic, “wild” • Key clinical features: social and interpersonal instability • Treatment: support, exploration, sociotherapy, individual therapy, medication • Course: unstable • Prognosis: some remission with age • Genetics: • More family members with mood disorders • Group see most frequently in clinical practice

33. Borderline Personality Disorder • A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

34. Borderline Diagnostic Criteria • Frantic efforts to avoid real or imagined abandonment. • 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: (spending, sex, substance abuse, reckless driving, binge eating).

35. Borderline Diagnostic Criteria • Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. • Affective instability due to a marked reactivity of mood. • Chronic feelings of emptiness. • Inappropriate, intense anger or difficulty controlling anger (frequent displays of temper, constant anger, recurrent physical fights). • Transient, stress-related paranoid ideation or severe dissociative symptoms.

36. Borderline Personality Disorder • Prevalence: 2-3% of the population • 2:1 female:male ratio • Most prevalent personality disorder in all clinical settings (12-15%) • 51% of all inpatients • 27% of all outpatients with a personality disorder • Increased risk for co-morbid mood disorders, eating disorders, substance abuse, PTSD • Up to 10% will have completed suicide by age 30 years • Increased prevalence of mood disorders in families of borderline patients

37. Borderline Personality Disorder • Usually diagnosed by age 40 years • Course is variable but rarely changes over time • Some patients improve in middle age • Treatment: several modes of psychotherapy • Dialectical behavioral therapy (DBT) • Instill intense counter-transference • Differential dx: bipolar disorder, schizotypal pd, histrionic pd, narcissistic pd, dependent pd, psychotic disorders

38. Antisocial Personality Disorder • Pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more):

39. Antisocial Diagnostic Criteria • 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, conning others for personal profit,pleasure • Impulsivity or failure to plan ahead.

40. Antisocial Diagnostic Criteria • Irritability & aggressiveness, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. • Lack of remorse, as indicated by being indifferent to, or rationalizing having hurt, mistreated, or stolen from another. • The individual is at least 18 years old. • There is evidence of conduct disorder with onset before age 15 years. • The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic episode.

41. Antisocial Personality Disorder • Sociopath, “morally bankrupt” • Disregard for rights of others and lack of remorse • Prevalence: 3% male; 1% female • Up to 75% of prison population • Occurs 5x more commonly in first-degree relatives of males with the disorder • Variable course • Differential dx: other Cluster B pd, substance abuse disorders, mania, mental retardation • Difficult if not impossible to treat

42. 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:

43. Histrionic Diagnostic Criteria • 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.

44. Histrionic Diagnostic Criteria • 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.

45. Histrionic Personality Disorder • 2-3% of the population • Females diagnosed more often • Males probably under-diagnosed • Variable course, often softens with age • Treatment is individual psychotherapy • Low dose benzodiazepines are useful for transient emotional states • Differential dx: dependent pd, borderline pd, narcissistic pd, somatization disorder

46. 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:

47. Narcissistic Diagnostic Criteria • 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.

48. Narcissistic Diagnostic Criteria • 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.

49. Narcissistic Personality Disorder • Overwhelming, pathological self-absorption • Primary motivation is power • Prevalence unknown; <1% general population, 2-15% clinical population • Chronic course • Co-morbid mood disorders common • Aging ultimate blow to self-esteem, prone to severe mid-life crises • Treatment individual psychotherapy • Do not tolerate group therapy • Differential dx: borderline pd, histrionic pd, antisocial pd

50. Cluster C: Avoidant, Dependant, Obsessive-Compulsive • Anxious and fearful, (“wimpy”) • Key clinical features: interpersonal and intrapsychic conflicts • Treatment: exploration, individual therapy, group therapy • Course: modifiable • Prognosis: good • Genetics: • More relatives with anxiety disorders