1
Q
Types of personality disorders
A
- paranoid
- schizoid
- schizotypal
- antisocial
- borderline
- histrionic
- narcissistic
- avoidant
- dependent
- obsessive compulsive
2
Q
Cluster A
A
Paranoid
Schizoid
Schizotypal
=appear odd or eccentric
5.7%
3
Q
Cluster B
A
antisocial
borderline
histrionic
narcissistic
= appear dramatic, emotional or erratic
1.5%
4
Q
Cluster C
A
avoidant
dependent
obsessive-compulsive
= appear anxious or fearful
6%
5
Q
Prevalences US
A
for any personality disorder = 9.1%
adult’s prevalence = 15%
6
Q
General personality disorder
A
- enduring pattern of inner experience and behaviour that deviates from the expectation of the individual’s culture in two or more of the ares:
1) cognition
2) affectivity
3) interpersonal functioning
4) impulse control - pattern is inflexible and pervasive across broad range of situations
- leads to significant distress or impairment in social, occupational or other functioning areas
- pattern is stable and of long duration (onset traced at least to YA or adolescence)
- not better explained by another mental disorder
- not attributable to effects of substance or medical condition
7
Q
Diagnostic features
A
- long term patterns of functioning
- evident by early adulthood
- distinguished from characteristics that emerge in response to situational stressors or more transient mental states (bipolar, depressive, anxiety, substance)
- stability of traits over time and situations
8
Q
Development and course of PD
A
- recognisable during adolescence or early adulthood
- pattern of thinking, feeling and behaving is relatively stable over time
- for younger than 18, features must be present for at least 1 year
9
Q
Individuals younger than 18 years can’t be diagnosed with
A
antisocial personality disorder
10
Q
PD more frequent in males
A
antisocial PD
11
Q
PD more frequent in women
A
borderline
histrionic
dependent
12
Q
PD that are related to psychotic disorders
A
paranoid
schizoid
schizotypal
13
Q
Differential diagnosis
A
- for PD related to psychotic disorders = pattern must not have occurred during the course of schizophrenia, a bipolar, depressive or another disorder
- cautious when diagnosing during episode of depressive or anxiety disorder
- personality change emerge after exposure to extreme stress => consider PTSD
- when individual has a substance use disorder = not make PD diagnosis bases on consequences of intoxication or withdrawal
- personality change due to medical condition
14
Q
Paranoid Personality Disorder
A
- pattern of distrust and suspiciousness that others’ motives are interpreted as malevolent
- beginning in early adulthood
- present 4 or more:
1) suspects, without enough basis, that others are exploiting, harming or deceiving them
2) preoccupied with unjustified doubts about loyalty and trustworthiness of close people
3) reluctant to confide (used against)
4) seeks hidden and threatening meanings
5) bears consistent grudges
6) perceives personal attack that are not apparent to others and reacts quickly
7) recurrent suspicions about fidelity of partner
15
Q
Associated features of Paranoid PD
A
- problems with close relationship
- hypervigilance => guarded, secretive => appear cold
- need to be self-sufficient and strongly autonomous
- high degree of control of people around
- unable to collaborate
- rigid and critical of others
- hardly accept criticism
- blame others for their shortcomings
- legal disputed
- unrealistic, hidden grandiose fantasies
16
Q
Prevalence of Paranoid PD
A
- 3%
- 4%
more prevalent in males
17
Q
Development of Paranoid PD
A
- first apparent in childhood and adolescence with: solitariness, poor relationships, social anxiety, unachievement in school, hyper sensibility, peculiar thoughts and language, idiosyncratic fantasies
18
Q
Prognostic Factor of Paranoid PD
A
- paranoid PD, delusional disorder and persecutory type in relatives
- pro bands with schizophrenia
- members of minority, refugees, defensiveness because of unfamiliarity
19
Q
Similarities between Paranoid and Schizotypal PD
A
suspiciousness
interpersonal aloofness
paranoid ideation
20
Q
Differences between Paranoid and Schizotypal PD
A
magical thinking (S)
unusual perceptual experiences (S)
odd thinking and speech (S)
21
Q
Similarities between Paranoid and Schizoid PD
A
individual perceived as strange, eccentric and cold
22
Q
Differences between Paranoid and Schizoid PD
A
prominent paranoid ideation (P)
23
Q
Similarities between Paranoid and Borderline + Histrionic PD
A
react to minor stimuli with anger
24
Q
Differences between Paranoid and Borderline + Histrionic PD
A
pervasive suspiciousness (P)
25
Similarities between Paranoid and Avoidant PD
reluctant to confide
26
Differences between Paranoid and Borderline PD
fear of being embarrassed (A)
| fear of malicious intent (P)
27
Similarities between Paranoid and Antisocial PD
antisocial behaviour
28
Differences between Paranoid and Antisocial PD
motivated by desire for personal gain or exploitation (A)
| motivated by desire of revenge (P)
29
Similarities between Paranoid and Narcissistic PD
suspiciousness
social withdrawal
alienation
30
Differences between Paranoid and Narcissistic PD
fears of having their flaws revealed (N)
31
Schizoid PD
detachment from social relationships and a restricted range of emotional expression
32
At least 4 of the following symptoms of Schizoid PD
1- neither desires nor enjoys close relationships
2- solitary activities almost always
3- little, if any, interest in sexual experiences
4- pleasure from only few or no activities
5- lacks close friends or confidants (outside family)
6- indifferent to praise or criticism
7- emotional coldness, detachment or flattened affect
33
Associated features supporting diagnosis of Schizoid PD
- difficulty expressing anger
- seem directionless
- react passively
- work under conditions of social isolation
- may experience brief psychotic episodes
34
Prevalence of Schizoid PD
uncommon in clinical settings
4.9 / 3.1 %
male prevalence (and harsher symptoms)
35
Development of Schizoid PD
- first apparent in childhood and adolescence with solitariness, poor relationships and unachievement
- subjected to teasing
36
Prognostic factors of Schizoid PD
- relatives with schizotypal PD or schizophrenia
| - erroneously labels as schizoid: immigrants
37
It is hard to differentiate Schizoid PD from
milder forms of autism spectrum disorder
38
Difference from Schizoid PD and autism is
that autism has more severely impaired social interactions + stereotyped behaviours and interests
39
Differences of Schizoid PD and other PD's
Schizotypal and paranoid: cognitive and perceptual distortions (schizoid) and suspiciousness or ideation (paranoid)
Avoidant: fear of embarrassment and rejection (A) / limited desire for social intimacy (S)
Obsessive-compulsive: devotion to work and discomfort with emotions (OC) + there is desire for intimacy (OC)
40
Differences between Loners and Schizoid PD
for loners it does not cause significant impairment or subjective distress + traits are inflexible
41
Schizotypal PD
social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as cognitive or perceptual distortions and eccentricities of behaviour
42
At least 4 of the following symptoms of Schizotypal PD
```
1- ideas of reference (illusions that events relate to oneself)
2- odd beliefs or magical thinking
3- unusual perceptual experiences
4- odd thinking and speech
5- inapropriate affect
6- behaviour or appearance is peculiar
7- lack of close friends and confidants
8- excessive social anxiety that does not diminish with familiarity + associated with paranoid fears
```
43
It is important that symptoms of Schizotypal PD do not occurs exclusively during
the course of schizophrenia, bipolar, depressive with psychotic features, another psychotic disorder or autism
44
Diagnostic features of Schizotypal PD
- social and interpersonal deficits marked by reduced capacity for close relationships and perceptual distortions
- ideas of reference: incorrect interpretations of events as having personal meaning
- delusions of reference: beliefs held with delusional conviction
45
Associated features of Schizotypal PD
- seek treatment for symptoms associated with anxiety and depression
- in response to stress => transient psychotic episodes
46
Prevalence of Schizotypal PD
- 3.9% in general population
- infrequent in clinical populations (0-1.9)
- slightly more in males
47
Prognostic factors of Schizotypal PD
- relatives with schizophrenia
| - some extreme religious rituals may appear schizotypal to the outsider
48
Differential diagnosis of Schizotypal PD
- period of persistent psychotic symptoms is present only for delusional disorder, schizophrenia bipolar or depressive with psychotic features
- difficult to differentiate from solitary odd children, who exhibit social isolation, eccentricity, peculiarities of language
- difference from autism: in A is even greater the lack of social awareness and emotional reciprocity, stereotyped behaviours and interests
- difference from language communication disorder: in LCD there is a primacy and severity of impaired language
49
Similarities of Schizotypal and Avoidant PD
limited close relationships
50
Differences of Schizotypal and Avoidant PD
A: active desire for relationships is constrained by fear of rejection
S: lack of desire for relationships + detachment
51
Similarities of Schizotypal and Narcissistic PD
suspiciousness
social withdrawal
alienation
52
Differences of Schizotypal and Narcissistic PD
fears of having imperfections and flaws revealed (N)
53
Similarities of Schizotypal and Borderline PD
transient, psychotic like symptoms
| social isolation
54
Differences of Schizotypal and Borderline PD
- affective shifts in response to stress (B)
- more dissociative (B)
- psychotic like symptoms that may worsen under stress but are less likely to be invariably associated with pronounced affective symptoms (S)
- social isolation is secondary to repeated interpersonal failures due to anger and mood shifts (B)
- social isolation as result of lack of social contact and desire for intimacy (S)
- don't usually demonstrate the impulsive or manipulative behaviours of Borderline (S)
55
Differences between Schizotypal PD and schizotypal features during adolescence
-may be reflective or transient emotional issues, rather than enduring PD
56
Antisocial PD
- disregard for and violation of the rights of others, occurring since age 15
57
At least three of the following for antisocial PD
- failure to conform to social norms with respect to lawful behaviours, indicated by repeating acts leading to arrest
- deceitfulness
- impulsivity or failure to plan
- irritability and aggressiveness (fights or assaults)
- disregard for safety of others
- consistent irresponsibility (work and financial obligations)
- lack of remorse
58
The patterns of antisocial PD have been previously referred to as
psychopathy
sociopathy
disocial personality disorder
59
Conduct disorder is a diagnostic feature of antisocial PD and it describes
persistent pattern of behaviour in which basic norms are violated:
- aggression
- destruction
- deceitfulness or theft
- serious violation of rules
60
Associated features of antisocial PD
- lack of empathy, cynical about sufferings of others
- arrogant self-appraisal
- superficial charm
- irresponsible and exploitive in sexual relationships
- irresponsible parents: malnutrition, illness, lack of hygiene etc
- fail to be self-supporting, may become homeless or spend years in penal institutions
- may die prematurely from violent means
- experience dysphoria, tension, inability to tolerate boredom, depressed moods
- associated anxiety, depressive, SUD, somatic symptom disorder, gambling and other impulsive control issues
- have personality features that meet criteria for borderline, histrionic, narcissistic
- conduct disorder before age of 10 and accompanying ADHD
- subject to child abuse or neglect, erratic parenting
61
Prevalence of Antisocial PD
- higher in people affected by socioeconomic and cultural factors
- 0.2% to 3.3%
- highest prevalence among males with SUD, in clinics, prisons (70%)
- males more often APD and SUD, while females have somatic symptom disorder
62
Antisocial PD gets less evident by
age 40
63
Diagnosis of Antisocial PD is not given to
- younger than 18
| - no symptoms of social conduct before 15yo
64
If patient supposedly has Antisocial PD and SUD
NO APD unless symptoms started in adolescence and continued now
65
Similarities between antisocial and narcissistic
- tendency to be superficial, exploitive and lack empathy
66
Differences between antisocial and narcissistic
- N does not include impulsivity, aggression and deceit
- A not as needy for admiration and envy
- N lack of history of conduct disorder
67
Similarities between antisocial and histrionic
- impulsive, superficial, excitement seeking, reckless, seductive and manipulative
68
Differences between antisocial and histrionic
- H more exaggerated emotions and not engaged in antisocial actions
- H manipulative to gain nurturance
69
Differences between antisocial and borderline
- B manipulative to get nurturance
- A manipulative to get profit
- A less emotionally unstable
- A more aggressive
70
In Paranoid PD, antisocial behaviours
May be present
71
Differences between antisocial and paranoid
- desire for personal gain and exploitation A
| - P desire for revenge
72
Borderline PD
- instability of interpersonal relationships, self-image, affects and impulsivity, beginnning by early adulthood
73
At least 5 of the symptoms for borderline
1. frantic effort to avoid real or imagined abandonment
2. unstable and intense personal relationships (extremes of idealization and devaluation)
3. identity disturbance
4. impulsivity in at least two areas that are self-damaging (spending, sex, substance abuse, reckless driving, binge eating)
5. Recurrent suicidal behaviour, thoughts or self-mutilation
6. affective instability marked by reactivity of mood (dysphoria, irritability or anxiety that lasts few hours)
7. Chronic emptiness
8. Intense anger and difficulty controlling it
9. transient, stress-related paranoid ideation or severe dissociation symptoms
74
Associated features of Borderline
- undermining themselves when goals is about to be realized
- psychotic like symptoms (hallucinations, body image dist., ideas of reference, hypnagogic phenomena)
- feeling more secure with transitional objects than relationships
- premature death from suicide may occur
- recurrent job losses, interrupted education and separations
- common child histories: physical and sexual abuse, neglect, hostile conflict, early parental loss
75
Common co-occuring disorders with Borderline
- depressive
- bipolar
- SUD
- eating disorders (especially bulimia)
- ptsd
- adhd
76
Prevalence
1.6-5.9%
6% in primary care setting
10% outpatient mental clinics
20% psychiatric inpatients
prevalence decreases with age
females 75%
77
Course of Borderline PD
- considerable variability
- chronic instability in early adulthood with episodes of serious affective discontrol and impulsiveness
- find more stability after 30-40's or after therapy
78
Similarities between Borderline and Histrionic
attention seeking
manipulative behaviour
rapidly shifting emotions
79
Differences between Borderline and Histrionic
self-destructiveness, angry disruptions in relationships, chronic feelings of emptiness or loneliness B
80
Similarities between Borderline and Schizotypal
- paranoid illusions
81
Differences between Borderline and Schyzotypal
B more transient, interpersonally reactive and responsive to external structuring ideas
82
Similarities between Borderline, Narcissistic and Paranoid
angry reaction to stimuli
83
Diff between Borderline, Narcissistic and Paranoid
P & N: relative stability of self image, lack of self-destructiveness, impulsivity and abandonment issues
84
Similarities between Borderline and Antisocial
manipulative behaviour
85
Diff between Borderline and Antisocial
A: manipulative to gain profit or gratification
B: gaining concern of caretakers
86
Similarities between Borderline and Dependent
fear of abandonement
87
Diff between Borderline and Dependent
B: reacts to abandonment with emotional emptiness, rage and demands
D: reacts with increasing appeasement and submissiveness and urgent seek of a replacement relationship to provide support
B: pattern of unstable relationship + intense
88
Histrionic PD
- excessive emotionality and attention seeking
89
At least five symptoms for Histrionic PD
1. uncomfortable in situations in which person is not center of attention
2. interactions are sexually seductive or provocative
3. rapid shift of emotions and expression
4. uses physical appearance to draw attention
5. speech excessively impressionistic and lacking detail
6. self dramatization, theatricality and exaggerated expression of emotion
7. being suggestible (easily influenced)
8. considers relationship more intimate than they actually are
90
Associated features of Histrionic PD
- difficulty achieving intimacy in relationships
- acting out as role without being aware (victim, princess)
- control their partner through emotional manipulation or seductiveness, while also displaying dependency
- have impaired relationships with same-sex friends because their sexually provocative interpersonal style may seem a threat to the friends' relationships
- alienate friends with demands for constant attention
- depressed when not center of attention
- crave novelty, stimulation and excitement and tend to become bored with usual routine
- seek immediate satisfaction and are frustrated by delayed gratification
- interest lags quickly in project initiated with enthusiasm
- increased risk for suicidal gestures and threats in order to get attention
- risk for somatic symptoms disorder, conversion disorder or major depressive
91
Prevalence
1.84%
females
co-occur often with borderline, narcisisstic, antisocial and dependent
92
Narcissistic PD
- grandiosity in fantasy or behaviour, need for admiration, lack of empathy
93
At least five symptoms for Narcissistic PD
1. grandiose sense of self importance (exaggerates achievements and talents to be recognized as superior)
2. preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love
3. believes they are special and unique and can be understood only by special people
4. requires excessive admiration
5. sense of entitlement
6. interpersonally exploitative
7. lack empathy
8. often envious and believes others are envious of him
9. arrogant attitudes
94
Associated features for Narcissistic PD
- vulnerability in self esteem => sensitive to criticism or defeat and may react with race or counterattack
- impaired interpersonal relationships because of entitlement, need for admiration and relative disregard to others
- overweening ambition => high achievement but performance can be disrupted due to criticism
- unwillingness to take a risk in a competitive situation where defeat is possible
- feelings of shame and self-criticism lead to social withdrawal, depressive mood, dysthymia or MDD
- sustained periods of grandiosity are associated with a hypomanic mood
- associated with anorexia nervosa or SUD (cocaine)
- associated with histrionic, borderline, antisocial, paranoid
95
Prevalence
0 to 6.2%
prevalent in male
96
Development
- adolescents can have narcissistic trait without being necessary that NPD will be present
- difficulties adjusting to physical or occupational limitations due to age
97
Avoidant PD
- social inhibition
- feelings of inadequacy
- hypersensitivity to negative evaluation
98
At least four symptoms for Avoidant PD
1. avoids occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval or rejection
2. unwilling to get involved with people unless certain of being liked
3. restraint within intimate relationships because of fear of rejection, shame
4. preoccupied with being criticized or rejected
5. inhibited in new interpersonal situations because of feelings of inadequacy
6. views self as socially inept, personally unappealing or inferior
7. reluctant to take personal risk or new activities because of not being embarrassed
99
Associates features of Avoidant PD
- vigilantly appraise movements of those in contact
- fearful and tense => may elicit ridicule from others => confirms self doubts
- anxious that they will blush or cry
- major problems in social and occupational functioning
- relatively isolated + no large social support
- desire affection and acceptance and may fantasize about idealized relationships
100
Avoidant PD can often be co-diagnosed with
dependent personality D
borderline
cluster A
depressive, bipolar, anxiety, social phobia
101
Prevalence of avoidant PD
2.4%
equal in male and female
102
Dependent PD
- excessive need to be taken care of that leads to submissive and clinging behaviours
fears of separation
103
Five or more symptoms for Dependent PD
1. difficulty making everyday decisions without excessive advice and reassurance
2. needs others to assume responsibility for most major areas of his life
3. difficulty expressing disagreement with others => fears of loss of support of approval (but no fear of retribution)
4. difficulty initiating projects on their own (no self confidence)
5. goes to excessive lengths to obtain nurturance and support from others (doing unpleasant things)
6. unconfortable and helpless when alone because of fears of not being able to take care of self
7. urgently seeks another relationship as source of care
8. unrealistically preoccupied with fears of being left to take care of self
104
Associated features of Dependent PD
- pessimism and self doubt, believe to be stupid
- take criticism and disapproval as proof of worthlessness
- seek overprotection and dominance
- limited social relations only to those towards whom dependence is directed
105
Prevalence of Dependent PD
0.49-0.6%
females
106
Obsessive compulsive PD
preoccupation with orderliness, perfectionism and mental and interpersonal control
at the expense of flexibility, openness, efficiency
107
Four or more symptoms for OCPD
1. preoccupied with details, rules, lists, order, organization and scheduling => major point of activity is lost
2. perfectionism that interferes with task completion (unable to complete project because own standards not met)
3. excessively devoted to work and productivity, over leisure activities and friends
4. scrupulous and inflexible about matters of morality, ethics and values
5. unable to discard worn-out objects
6. reluctant to delegate work
7. misery spending style => money kept for worse times
8. rigid and stubborn
108
Associated features of OCPD
- decision making becomes painful and time consuming
- difficulties prioritizing
- angry and upset when no in control, although don't show it
- express affection in a highly controlled manned and feel uncomfortable under people who do it freely
- everyday relationships are formal and serious
- carefully hold back what they want to say until sure it is perfect
- preoccupied with logic and intellect => intolerant of affective behaviours of others
109
Other disorders that can meet criteria for OCPD are
```
anxiety
GAD
Social anxiety
depressive
bipolar
eating disorders
```
110
Majority of people with OCD do not have
a pattern that meets criteria for OCPD
111
Prevalence
one of the most prevalent, 2.1% to 7.9%
twice as often among males
112
OCD is distinguished from OCPD by
the presence of true obsessions and compulsions in OCD
113
Diagnosis of hoarding disorder can be considered when
hoarding is extreme
114
3P's of personality disorders are
Persistent
Pervasive (contexts)
Pathological (deviates from normal)
115
Etiology of personality disorders
- no specific cause but
- diathesis stress model
- a lot of comorbidity => role of genes
116
Diathesis stress model
Diathesis: genes, abnormalities of brain structure of functioning, neurotransmitters => vulnerability to psychological disorders
Stressors: physical, trauma, abuse, neglect, relationship lose or turbulence, culture related
Diathesis + Stressors = PD
117
Cluster B are more known because of
impact on society
118
OCD and OCPD are ego-
OCD - dystonic (I don't like it but I have to)
OCPD - syntonic ( I care about the rules and so should you)
4.2C Personality Disorders
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