ersona||ty D|sorder

Def|n|t|ons
- ersonallLy LralLs
! Lndurlng paLLerns of percelvlng, Lhlnklng abouL and relaLlng Lo Lhe envlronmenL and
oneself LhaL are exhlblLed ln a wlde range of soclal and personal conLexLs
- ersonallLy dlsorder
! When Lhese LralLs are perslsLenLly lnflexlble and maladapLlve, sLable over Llme, and
cause slgnlflcanL personal dlsLress or funcLlonal lmpalrmenL
! aLlenLs do noL regard Lhelr paLLerns of behavlour and coplng sLyle as lnherenLly
abnormal
- 30-60 of paLlenLs wlLh a psychoLlc dlsorder also have a personallLy dlsorder
- uSM-lv
! Axls ll = personallLy dlsorders and menLal reLardaLlon
! Axls l = ma[or menLal lllnesses (e.g. psychoLlc and mood dlsorders)

C|ass|f|cat|on of C||n|ca| Ieatures
- Acquired vs. Specific personality disorder
! Acqulred ersonallLy ulsorder
ulsordered personallLy clearly develops afLer, and ls dlrecLly relaLed Lo, a
recognizable insult
Lxample:
Crganlc personallLy dlsorder = resulLs when lnsulL ls some form of
braln damage or dlsease:
! L.g. 8raln Lumour, sLroke
! CharacLerlzed by
Soclal dlslnhlblLlon (e.g. sLeallng, sexual
lnapproprlaLeness)
AbnormallLles of emoLlonal expresslon (e.g.
aggresslon, apaLhy, shallow cheerfulness)
! 1yplcally seen ln fronLal lobe leslons
osL-caLasLrophlc evenL personallLy change
uevelopmenL of a severe psychlaLrlc lllness
! Speclflc ersonallLy ulsorders
lar more prevalenL
ulfflculL Lo flnd a dlrecL causal relaLlonshlp wlLh any one speclflc Lhlng
CeneLlc and envlronmenLal facLors lmpllcaLed
CnseL ln adolescence or early adulLhood
8emalns relaLlvely sLable over Llme


- ulmenslonal vs. caLegorlcal Lo classlflcaLlon
! ulmenslonal approach
PypoLheslzes LhaL Lhe personallLy LralLs of paLlenLs wlLh a personallLy
dlsorder dlffer from Lhe normal populaLlon only ln Lerms of degree
LxlsLlng on a conLlnuum LhaL merges lnLo normallLy
used ln research and personallLy lnvenLorles (e.g. MMl)
! CaLegorlcal approach
Assumes Lhe exlsLence of dlsLlncL Lypes of personallLy dlsorder
Classlfles paLlenLs lnLo dlscreLe caLegorles
Conslderable overlap of LralLs, mosL do noL flL perfecLly lnLo Lhese descrlbed
caLegorles
used by lCu-10 and uSM-lv


ersona||ty C|usters
- ClusLer A
! uescrlbes lndlvlduals who appear odd and eccenLrlc
! lncludes paranold, schlzold, schlzoLypal personallLy dlsorders
- ClusLer 8
! uescrlbes lndlvlduals who appear dramaLlc, emoLlonal, or erraLlc
! lncludes borderllne, anLlsoclal (dlssoclal), hlsLrlonlc, and narclsslsLlc personallLy
dlsorders
- ClusLer C
! uescrlbes lndlvlduals who appear anxlous or fearful
! lncludes avoldanL, dependenL, and obsesslve-compulslve (anankasLlc) personallLy
dlsorders
*Ma[orlLy of paLlenLs wlLh CCu uC nC1 meeL Lhe crlLerla for obsesslve-compulslve
personallLy dlsorder














Categor|ca| C|ass|f|cat|on of ersona||ty D|sorders
Cluster A: odd or eccentric
aranold personallLy dlsorder - SuspecLs oLhers are explolLlng, harmlng, or decelvlng Lhem
- Doubts about spouses fidelity
- 8ears grudges
- 1enaclous sense of personal rlghLs
- LlLlglous
Schlzold personallLy dlsorder - LmoLlonal coldness
- nelLher en[oys nor deslres close or sexual relaLlonshlps
- refers sollLary acLlvlLles
- 1akes pleasures ln few acLlvlLles
- lndlfferenL Lo pralse or crlLlclsm
SchlzoLypal personallLy dlsorder - LccenLrlc behavlour
- Cdd bellefs or maglcal Lhlnklng
- Unusual perceptual experiences (e.g. senses anothers presence)
- ldeas of reference
- Susplclous or paranold ldeas
- vague or clrcumsLanLlal Lhlnklng
- Soclal wlLhdrawal
Cluster B: dramatic, emotional, erratic
8orderllne personallLy dlsorder - LmoLlonally unsLable
- lnLense, chaoLlc relaLlonshlps (flucLuaLlng beLween exLremes of
ldeallzaLlon and devaluaLlon)
- 8lack and whlLe Lhlnklng, spllLLlng
- unsLable self-lmage
- lmpulslvlLy (sex, blnge-eaLlng, subsLance abuse, spendlng)
- 8epeLlLlve sulcldal or self-harm behavlour
- llucLuaLlons ln mood
- lranLlc efforLs Lo avold abandonmenL (real or lmaglned)
- 1ranslenL paranold ldeaLlon or dlssoclaLlon
AnLlsoclal personallLy dlsorder - ulssoclal
- 8epeaLed unlawful or aggresslve behavlour
- uecelLfulness, Lylng
- 8eckless lrresponslblllLy
- Lack of remorse or lncapaclLy Lo experlence gullL
- CfLen have conducL dlsorder ln chlldhood
PlsLrlonlc personallLy dlsorder - uramaLlc personallLy dlsorder
- LxaggeraLed expresslons of emoLlon, lablle shallow emoLlons
- ALLenLlon seeklng
- SeducLlve behavlour
narclsslsLlc personallLy dlsorder - Crandlose sense of self-lmporLance
- need for admlraLlon
Cluster C: anxious or fearful
uependenL personallLy dlsorder - Lxcesslve need Lo be cared for, Submlsslve
- Cllnglng behavlour
- needs oLhers Lo assume responslblllLy for ma[or llfe areas
- lear of separaLlon
AvoldanL personallLy dlsorder - Anxlous personallLy dlsorder
- PypersenslLlvlLy Lo crlLlcal remarks or re[ecLlon
- lnhlblLed ln soclal slLuaLlons
- lears of lnadequacy
Cbsesslve-compulslve
personallLy dlsorder
- reoccupaLlon wlLh orderllness
- erfecLlonlsm and conLrol
- uevoLed Lo work aL expense of lelsure
- edanLlc, rlgld, and sLubborn
- Cverly cauLlous
Assessment
C||n|ca|
- llnd sources of dlsLress (LhoughLs, emoLlons, behavlour, and relaLlonshlps) Lo self and oLhers
- Assess for co-morbld menLal lllness
- Lxplore speclflc lmpalrmenLs of funcLlonlng aL work, home, or ln soclal clrcumsLances
- ConducL seml-sLrucLured lnLervlews
Se|f-kat|ng Instruments
- Self-reporL quesLlonnalres
- Lx. MMl (MlnnesoLa MulLlphaslc ersonallLy lnvenLory)


D|fferent|a| D|agnos|s
- Schlzophrenla
! Soclal wlLhdrawal, susplclousness, eccenLrlc ldeas
- uepresslon
! Self-harm, low mood, poor self-lmage
- SubsLance Abuse or Manla
! Aggresslon, lrresponslblllLy, lmpulslvlLy


D|agnos|s 1|ps
- Many paLlenLs wlLh ma[or menLal lllness have concurrenL personallLy dlsorder
- ersonallLy dlsorder should only be dlagnosed when Lhe cllnlcal feaLures:
! begln ln adolescence or early adulLhood
! are sLable over Llme
! do noL only occur durlng an eplsode of a ma[or menLal lllness (e.g.
depresslve/manlc/psychoLlc eplsode)
- When dramaLlc personallLy change, conslder:
! Crganlc personallLy dlsorder
! ersonallLy dlsorder 2 Lo experlenclng a caLasLrophlc evenL
! ueveloplng a severe psychlaLrlc lllness



Lp|dem|o|ogy & Lt|o|ogy
- revalence ln communlLy = 4-13
- LnvlronmenLal and geneLlc facLors
! 1wln sLudles hlgher concordance
! ClusLer A more common ln relaLlves of paLlenLs wlLh schlzophrenla
! uepresslve dlsorders more common ln relaLlves of paLlenLs wlLh borderllne
personallLy dlsorder
! x?? chromosomes show lncreased anLlsoclal behavlour
- neuroLransmlLLers lmpllcaLed
! Aggresslve or sulcldal paLlenLs low levels of seroLonln meLabollLe 3-PlAA
- Larly adverse soclal clrcumsLances
! AssoclaLed wlLh Lhe developmenL of dependenL and borderllne personallLy dlsorders
- Chlldhood sexual abuse assoclaLed wlLh borderllne personallLy dlsorder
- sychoanalyLlcal Lheory:
! lallure Lo successfully progress Lhrough Lhe sLages of psychosexual developmenL
wlLh Lhe subsequenL developmenL of characLerlsLlc defence mechanlsms (e.g.
pro[ecLlon ln paranold personallLy dlsorder, spllLLlng ln borderllne)

Lp|dem|o|ogy of ersona||ty D|sorders
ersona||ty D|sorder reva|ence |n Gen. op. Comments
aranold 0.3-2.3 M>l
ln low SLS
ln relaLlves of schlzophrenlc paLlenLs
Schlzold 0.3-1.3 M>l
ln prlson populaLlon
ln relaLlves of schlzophrenlc paLlenLs
SchlzoLypal 3
!"#$%&"' )*+
ln relaLlves of schlzophrenlc paLlenLs
8orderllne
(LmoLlonally unsLable)
2 l>M
ln younger age group
MosL severe ln mld-20s (improves in 30s)
AssoclaLed wlLh:
- oor work hlsLory
- Slngle marlLal sLaLus
Co-morbld wlLh:
- uepresslon
- SubsLance abuse
- 8ullmla
- AnxleLy
9 sulclde raLe
Regular patients/Frequent flyers
AnLlsoclal
(ulssoclal)
3 male
<1 female
M>>>l
MosL prevalenL ln 23-44 y.o.
AssoclaLed wlLh:
- School drop-ouL
- ConducL dlsorder
- urban seLLlngs
ln prlsons
Plghly co-morbld wlLh subsLance abuse
PlsLrlonlc 2-3 M=l (prevlously LhoughL l>M)
AssoclaLed wlLh parasulclde
narclsslsLlc <1 M>l
ln forenslc seLLlngs
uependenL 1-2 Co-morbld wlLh borderllne personallLy dlsorder
AvoldanL
(Anxlous)
1-3 M=l
Co-morbld wlLh soclal phobla
Cbsesslve-Compulslve
(AnankasLlc)
1-2 M>l
ln Caucaslans
ln hlghly educaLed
ln marrled
ln employed lndlvlduals



Management

sychosoc|a| Intervent|ons
- AsslsLance wlLh soclal problems
! L.g. houslng, flnances, employmenL, dlsLurbed relaLlonshlps
- SupporLlve psychoLherapy
! rovldes paLlenLs wlLh an auLhorlLy flgure durlng Llmes of crlsls
! locuses on accepLance and helplng paLlenLs wlLh Lhelr dependence needs
- C81
! CognlLlve behavloural Lherapy
! 1argeL speclflc sympLoms or behavlours
! L.g. depresslon, anxleLy, anger, dellberaLe self-harm
- CA1
! CognlLlve analyLlc Lherapy
! useful for borderllne personallLy dlsorder
- u81
! ulalecLlcal behavlour Lherapy
! lor borderllne personallLy dlsorder
! parasulcldal behavlour and Llme spenL ln hosplLal
! lmprove paLlenL engagemenL and soclal and global funcLlonlng
- AC1
! AsserLlve communlLy ouLreach programs
- Croup or lndlvldual psychodynamlc psychoLherapy



harmaco|og|ca| 1reatment
- Mood sLablllzers
! LlLhlum, carbamazeplne
! useful ln LreaLlng aggresslon, lmpulslvlLy, mood lnsLablllLy
- AnLlpsychoLlcs
! 1reaLlng psychoLlc sympLoms someLlmes seen ln schlzoLypal and borderllne
personallLy dlsorder paLlenLs
! parasulcldal behavlour
! Pelp wlLh lmpulslvlLy, aglLaLlon, and aggresslon
- AnLldepressanLs
! 1reaLlng depresslve sympLoms
! SS8ls may help wlLh obsesslve-compulslve sympLoms, lmpulslvlLy, and self-harm
behavlour
- 8enzodlazeplnes
! AllevlaLes acuLe anxleLy
! SedaLes an acuLely aglLaLed or aggresslve paLlenL
! use wlLh cauLlon may lead Lo dependence


Course & rognos|s
- aLlenLs wlLh personallLy dlsorders lncldence of oLher menLal lllnesses (e.g. depresslon,
anxleLy, schlzophrenla), also Lend Lo be more severe
- Plgher raLes of sulclde and accldenLal deaLh Lhan general populaLlon (esp. clusLer 8)
- 30 of borderllne personallLy paLlenLs show recovery aL 10-23 year follow-up
- SchlzoLypal and obsesslve=compulslve personallLy dlsorders sLable over Llme (schlzoLypal
may progress Lo schlzophrenla)