PERSONALITY DISORDER 2 Hours

PERSONALITY DISORDER 2 Hours
Personality:
The distinctive set of characteristics that defines the emotions, thoughts, perception and behavior or an individual’s personal style and influence his interactions with the environment.

Characters:
Personal qualities that represent the individual’s adherence to the value and customs of society, (a moral standard is applied here).
• Temperament:
The biological constitutions and dispositions that underlie the tendency to respond to stimulation in particular ways, and colour the moods of the individual. The term “temperament” is used when talking about children and adolescents characteristics (before the age at which the personality is well formed).
Traits:
Prominent enduring aspects and qualities of a person.

In ICD-10, personality disorders are described as severe disturbance of personality and behavior that are pronounced deviations, from normal cultural patterns.
According to DSM-IV, the crucial criterion for distinguishing deviant personality traits is the presence (evidence) of long-term maladaptation and inflexibility, manifested as subjective distress, or socio professional functional impairment, or both. DSM-IV defines personality disorders as:
an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual s culture. The pattern is manifested in two (or more) of the following areas:
1.cognition (i.e., ways of perceiving and interpreting self, other people, and events)
2.affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)
3.interpersonal functioning
4.impulse control
The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood. It is inflexible and pervasive across a broad range of personal and social situations and leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
COURSE:
The features of a personality disorder usually become recognizable during adolescence or early adult life.
The development of a change in personality in middle adulthood or later life warrants a thorough evaluation to determine the possible presence of a personality change due to a general medical condition or an unrecognized substance – related disorder.
Determinants of Personality and its Disorders
? Biological factors (genetics, perinatal injury…)
? Family environment (abuse, deprivation…)
? Psychological factors (cognitive distortions…)
? Social factors (poverty, migration…)
Personality Assessment: It is important to know how to assess the personality because:
1. Personality traits need to be differentiated from episodes of mental illness. However, coexistence of the two is common in clinical practice.
2. Pathology of personality can increase the vulnerability to maladjustment to psychological and physical stresses.
3. Presence of personality disorder can alter the presentation of mental disorder, which may complicate the clinical picture and make the final diagnosis difficult.
4. The treatment of a mental disorder is more difficult when the patient has personality pathology.

Aspects to assess:
• Emotional reactivity and stability.
•Social relationships.
• Intellectual abilities.
• Motives and self-control.
• Frustration tolerance and ability to deal with stress.
• Judgment, decision-making, and problem solving.
• Beliefs, attitudes and moral standards.
• Habits and hobbies.

How to assess?
The following sources of information can be considered:
1. observing the patient in various circumstances.
2. patient’s own description of his own personality (however, caution should be exercised because personal evaluation is at a high of bias).
3. the reports and views of other informants who are acquainted with the patient (e.g. a spouse, a parent, a closed friend…).
4. patient’s account of his behavior in a variety of past circumstances.
5. certain psychological tests of personality which are usually applied by a clinical psychologist.
The most commonly used tests are:
• Minnesota Multiphasic Personality Inventory (MMPI)
• Eysenk Personality Inventory (EPI)
DSM-IV arranges categorical personality disorders into three clusters, each sharing some clinical features:
*Cluster A includes three disorders with odd, aloof, and eccentric features (paranoid, schizoid, and schizotypal).
*Cluster B includes four disorders with dramatic, impulsive, and erratic features (borderline, antisocial, narcissistic, and histrionic).
*Cluster C includes three disorders sharing anxious and fearful features (avoidant, dependent, and obsessive-compulsive).

Cluster A Personality Disorders

Paranoid Personality Disorder: The hallmarks of paranoid personality disorder are excessive suspiciousness and distrust of others expressed as a pervasive tendency to interpret actions of others as deliberately demeaning, malevolent, threatening, exploiting, or deceiving). Frequently impairment is mild, but the disorder typically includes occupational and social difficulties. These patients are at increased risk for major depressive disorder, obsessive-compulsive disorder, agoraphobia, and substance abuse or dependence. Paranoid personality disorder has been postulated to be a prepsychotic antecedent of delusional disorder, paranoid type. Paranoid personality disorder is distinguished from schizophrenia (especially paranoid type), delusional disorder, paranoid type, and mood disorder with psychotic features on the basis of periods with positive psychotic symptoms such as delusions and hallucinations in the latter.
• Features:
? Suspiciousness of others without sufficient basis.
? Mistrust of others’ motives.
? Unjustified excessive doubts about the loyalty of friends or associates.
? Sensitivity to offenses.
? Exaggerated perception of imagined threatening meanings or hidden demeaning of benign events and remarked, with ideas of reference.
? Exaggerated counter attacking and reacting angrily with abusive behaviour.
? Exaggerated bearing of grudges persistently (e.g. insults, slights, injuries…).
? Excessive jealousy and competition.
? Projection of faults and on others and avoidance of accepting blame when it is deserved.
? Stubbornness and tendency to argumentations.

Schizoid Personality Disorder :The hallmarks of schizoid personality disorder are a pervasive pattern of social detachment and a restricted range of expressed emotions in interpersonal settings. Frequently these individuals exhibit severe problems in social relations and occupational problems when interpersonal involvement is required. Social isolation sometimes favorably affects overall performance. This personality disorder sometimes appears as the prepsychotic antecedent of delusional disorder, schizophrenia, or (rarely) major depressive disorder. Schizoid personality disorder is distinguished from schizophrenia, delusional disorder, and mood disorder with psychotic features on the basis of periods with positive psychotic symptoms, such as delusions and hallucinations, in the latter.
• Features:
? Social isolation (few close friends) .
? Emotional coldness and restricted range of emotional expression.
? Self-sufficiency. ? Choosing solitary activities and jobs.
? Indifference to praise, criticism and feelings of others.
? Little interest in having sexual experiences with another person (spouse)
? Excessive daydreams and fantasies
? Lack of social skills.
Schizoid person is attracted by nonhuman interests (e.g. computer, mathematics, philosophy…) and is able to invest enormous intellectual and affective energy in such interest giving creative ideas and actions.
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Schizotypal Personality Disorder: The hallmarks of schizotypal personality disorder are pervasive discomfort with and reduced capacity for close relationships, as well as cognitive and perceptual distortions and eccentric behavior (not severe enough to meet criteria for schizophrenia) magical thinking, oddities in speech, appearance, and thought processes). Patients with this disorder typically experience occupational and social difficulties.
Transient psychotic episodes can complicate this disorder, particularly in response to stress. Symptoms sometimes become so significant that subjects may meet criteria for schizophreniform disorder, delusional disorder, or brief psychotic disorder. More than a half of these patients have had at least one episode of major depression, and 30 to 50 percent have major depression concurrent with this personality disorder.
• Features:
? Odd or peculiar patterns of thinking, speech belief, behavior or appearance.
? Excessive social anxiety associated with suspiciousness.
? Unusual perceptual experiences (e.g. bodily illusions)
? Constricted or inappropriate affect.
? Ideas of reference.
Cluster B Personality Disorders

Antisocial Personality Disorder: is characterized by pervasive disregard for, and violation of, rights of others since the age of 15. A person must be at least 18 years old and have displayed evidence of conduct disorder before the age of 15. Antisocial personality disorder may be complicated by dysphoria, tension, low tolerance for boredom, depressed mood, and premature violent death. Impairment is extremely variable, but typically includes social difficulties.

DSM-IV Diagnostic Criteria for Antisocial Personality Disorder
A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 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 15 years.
D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic episode.

Narcissistic Personality Disorder: The hallmarks of narcissistic personality disorder are a pervasive sense of grandiosity (in fantasy or in behavior), need for admiration, lack of empathy, and chronic intense envy. These patients are at increased risk for major depression and substance abuse or dependence (especially cocaine use). Dysthymic disorder or major depressive disorder may develop in reaction to criticism or failure.
Features:
? Exaggerated self-importance and superiority.
? Preoccupation with success and power.
? Excessive and unrealistic (fantasies).
? Constant seeking of admiration.
? Excessive concern about appearance (more than substance).
? Relationships with others are characterized by lack of empathy, hypersensitivity to criticism and exploitation of others.
? Over preoccupation with feelings of envy.
? Fragile self-esteem.

Histrionic Personality Disorder :The hallmarks of histrionic personality disorder are pervasive and excessive self-dramatization, excessive emotionality, and attention seeking. The patients may exhibit frequent suicidal gestures. Interpersonal relations are unstable, shallow, and generally ungratifying. Frequent marital problems result from the tendency to neglect long-term relationships for the excitement of new relationships. These patients are at increased risk for major depression, somatization disorder, and conversion disorder.


DSM-IV Diagnostic Criteria for 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:
(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.

Borderline Personality Disorder The hallmarks of borderline personality disorder are pervasive and excessive instability of affects, self-image, and interpersonal relationships as well as marked impulsivity.
The disorder may be complicated by psychotic-like symptoms (hallucinations, body image distortions, hypnagogic phenomena, ideas of reference) in response to stress and premature death or physical handicap from suicide and suicidal gestures, failed suicide, and self-injurious behavior. Frequent and severe impairment may involve frequent job losses, interrupted education, and broken marriages.
These patients are at increased risk for major depression, substance abuse or dependence, eating disorder (notably bulimia), posttraumatic stress disorder, and attention-deficit/hyperactivity disorder.
• Features:
? Unstable mood, behavior and relationships.
? Identity disturbance (uncertainty about self-image and goals…).
? Persistent feelings of emptiness and boredom.
? Insistence on immediate gratification of needs.
? Impulsive behavior with poor planning.
? Self – mutilating and suicide(wrist cutting)behavior with anger outburst.
? Splitting (all bad or all good).
Cluster C Personality Disorders
Avoidant Personality Disorder Clinical Criteria Avoidant personality disorder is characterized by pervasive and excessive hypersensitivity to negative evaluation, social inhibition, and feelings of inadequacy. Impairment can be severe and typically includes occupational and social difficulties. These patients are at increased risk for mood and anxiety disorders (especially social phobia, generalized type).
• Features:
? Sensitivity to criticism and rejection.
? Fearfulness of disapproval.
? Timidity and shyness.
? Feelings of inadequacy in new situation.
? Reluctance to take personal risks.
? Very restricted number of friends.

DEPENDENT PERSONALITY DISORDER The hallmark of dependent personality disorder is a pervasive, excessive need to be taken care of, leading to clinging behavior, submissiveness, fear of separation, and interpersonal dependency . Complications include low socioeconomic status and poor family and marital functioning.
has difficulty making everyday decisions without an excessive amount of advice and reassurance from others , needs others to assume responsibility for most major areas of his or her life, has difficulty expressing disagreement with others because of fear of loss of support or approval.

• Features:
? Submissive and clinging behavior.
? Fear of separation
. ? Excessive compliance with others.
? Lack of self-reliance and self-confidence.
? Excessive demands for reassurance and advice.
? Excessive worries about abandonment.
? Difficulty in initiating tasks.

Obsessive-Compulsive Personality Disorder The hallmark of obsessive-compulsive personality disorder is pervasive preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. Complications include distress and difficulties when confronted with new situations that require flexibility and compromise and myocardial infarction (secondary to features typical of type A personalities, such as time urgency, hostility, competitiveness). Frequently severe, impairment typically includes occupational and social difficulties. These patients are at increased risk for major depression, anxiety disorder, and obsessive-compulsive disorder. Obsessive-compulsive personality disorder is distinguished from obsessive-compulsive disorder on the basis of true obsessions and compulsions in the latter.
• Features:
? Excessive perfectionism interfering with achievement (very idealistic views).
? Preoccupation with minor unnecessary details.
? Inflexibility and rigidity.
? Indecisiveness and hesitation .
? Excessive self-blame and guilt feeling.
? Precision about issues of morality.
? Excessive devotion (of time and energy) to work, at the expense of social life.
? Reluctance in delegating task to others.

Treatment
1. For those who seek help, individual and group psychotherapy may be useful.
2. Pharmacotherapy also can be used to treat symptoms, such as depression and anxiety, which may be associated with the PDs.
3. SSRI and anticonvulsant may be used to control impulsivity and aggressive behavior.