Personality Disorders

1. Personality Disorders Jacob Alexander BV PRCC

2. Personality Disorders • Personality Disorders refer to long- standing, pervasive and inflexible patterns of behaviour: • Depart from cultural expectations • Impair social occupational functioning • Cause emotional distress • Personality disorders are coded on Axis II of the DSM Personality disorders can be a co-morbid condition for an Axis I disorder

3. Fact sheet • Prevalence of Personality Disorders • About 0.5% to 2.5% of the general population • Rates are higher in inpatient and outpatient clinical settings • Origins and Course of Personality disorders • Thought to begin in childhood • Tend to run a chronic course if untreated • Co-morbidity rates are high • Gender distribution and gender bias in Diagnosis • Gender bias exists in the diagnosis of personality disorders • Such bias may be a result of criterion or assessment gender bias

4. Personality Disorder Clusters • Personality disorders fall into three general clusters: Persons in cluster A seem odd or eccentric • Paranoid, schizoid, schizotypal Persons in cluster B seem dramatic, emotional or erratic • Antisocial, borderline, histrionic, narcissistic Persons in cluster C appear as anxious or fearful • Avoidant, dependent, obsessive-compulsive Personality disorder not otherwise specified

5. Odd/Eccentric Cluster • Paranoid Personality disorder (PD) involves suspicion of others, hostility, jealousy -no hallucinations and no full blown delusions are present • Paranoid PD occurs more frequently in men than women • Lifetime prevalence is about 1%

6. Odd/Eccentric Cluster • Schizoid personality disorder involves • Reduced social relations and few friends • Reduced sexual desire and few pleasurable activities • Indifference to praise or criticism • Lonely life style • Prevalence of schizoid PD is less than 1% and occurs more commonly in men than women

7. Odd/Eccentric Cluster • Schizotypal personality disorder involves: • An attenuated form of schizophrenia • Odd beliefs and magical thinking • Recurrent illusions (things not present) • Ideas of reference (hidden meanings) • Behaviour and appearance is eccentric • Prevalence of schizotypal PD is about 3% and occurs slightly more commonly in men than women

8. Etiology of the Odd/Eccentric Cluster • These disorders are linked to schizophrenia and may represent a less severe form of the disorder: • Schizophrenia has clear genetic determinants • Family studies reveal that relatives of schizophrenic patients are at increases risk for developing schizotypal PD as well as paranoid PD • No clear pattern for scizoid PD

9. Dramatic/Erratic cluster • Borderline personality disorder involves • Impulsivity (gambling, spending, sexual sprees) • Instability in relationships, mood and self-image • Borderline PD persons are argumentative and difficult to live with • Prevalence of Borderline PD is about 1-2% and occurs more commonly in women than men • Linehan’s diathesis-stress theory • Difficulty controlling emotions (biological diathesis) • Raised in “invalidating” family environment

10. Emotional dysregulation in the child Emotional outbursts by child to which parents attend Great demands on the family Invalidation by the parents through punishing or ignoring the demands

11. The cluster B personality disorders • Borderline personality disorders • Narcissistic personality disorder • Antisocial personality disorder • Histrionic personality disorder

12. Borderline Personality Disorder • Unstable relationships- avoid abandonment • Poor self image- mood swings, feel empty • Impulsivity- substance abuse, sex, Suicidality • Causes • Runs in families • Connection with mood disorders • Contribution of early abuse • Treatment • Few controlled studies • Dialectical behavioural therapy • Medications- antidepressants, lithium, mood stabilisers

13. Histrionic Personality disorder • Symptoms • People who are overly dramatic and attention seeking • People who exhibit emotional displays but are emotionally shallow • People who are self-centred and overly concerned about physical attractiveness • Prevalence of histrionic pd is about 2-3% and occurs slightly more commonly in women than men

14. Narcissistic Personality disorder • Involves • A grandiose view of the person’s own importance • A strong sense of entitlement • A lack of empathy for others • Prevalence of narcissistic pd is less than 1% and this disorder co-occurs with borderline pd

15. Antisocial Personality disorder • Involves • The presence of conduct disorder before the age of fifteen • Conduct disorder includes truancy, lying, theft, arson, running away from home and destruction of property • The continuation of these behaviours into adulthood • Prevalence of antisocial pd is about 3% of men and 1% of women

16. Etiology of antisocial PD • Family issues may play a role in the development of antisocial PD • Lack of affection • Severe parental rejection • Inconsistent (or no) discipline • Twin studies show a greater concordance for antisocial PD in MZ twins relative to DZ twins • Adoption studies- adverse adoptive environment may be the stressor triggering the ASPD biological diathesis • Research studies on psychopaths

17. Antisocial Personality disorder • Treatment • Many do not seek treatment • Poor prognosis • Focus on prevention

18. Anxious/Fearful cluster • Anxious Avoidant personality disorder • Dependent personality disorder • Anankastic/obsessive personality disorder

19. Anxious avoidant personality disorder • Involves: • People who are fearful in social situations • People who are keenly sensitive to criticism, rejection or disapproval • People whose lives and job are restricted by their fear of negative interactions • Prevalence of avoidant pd is about 1% and this disorder is co-morbid with Dependent pd and Borderline pd

20. Anxious avoidant personality disorder treatment • Several well controlled studies • Target anxiety and social skills • Treatment similar to social phobia • Treatment modalities include systematic desensitization and behavioural rehearsal

21. Dependent Personality disorder • Symptoms: • A lack of self confidence • A lack of a sense of autonomy • A view that others are powerful while they are weak • Prevalence of dependent pd is about 1.5% and occurs slightly more commonly in women than men • May be related to insecure “anxious” attachment

22. Anakastic/obsessive personality disorder • Preoccupied with rules, orderliness and control • Inflexible, unwilling to show emotion or form close relationships • People with OCPD believe their thoughts are correct while people with OCD have unwanted thoughts • Perfectionism interfering with ability to complete tasks, because their standards are high and rigid • Emotionally withdraw when unable to control the situation • Rx- SSRIs, CBT, Psychodynamic psychotherapy

23. Therapies for Personality Disorders • Always look for co-morbid Axis I disorders • Therapy modalities include: -Anti-anxiety or antidepressant drugs -Psychodynamic therapy aims to change the person’s understanding of the childhood problems that underlie the PD -Behavioral and cognitive therapy focuses on specific symptoms and issues (e.g. social skills) • Overall therapeutic goal: change the “disorder” into a “style”, except for ASPD