Personality Disorders

Dr. Ahmad AlHadi

 Objectives
By the end of this lecture, you will be able to:
• Define personality disorders.
• List types of personality disorders.
• Know how to diagnose and treat personality
disorders.
 What are Personality Disorders?
• Personality is the way of thinking, feeling and behaving that
makes a person different from other people.
• An individual’s personality is influenced by experiences,
environment (surroundings, life situations) and inherited
characteristics. A person’s personality typically stays the
same over time.

• To be classified as a personality disorder, one's way of

thinking, feeling and behaving deviates from the
expectations of the culture, causes distress or problems
functioning, and lasts over time.
• Without treatment, personality disorders can be long-
lasting.
 Personality Traits
• Characteristic ways of thinking, feeling, and
behaving that are stable across time and
across situations

• Considered to be a disorder when

– Traits are inflexible and maladaptive
– Cause significant functional impairment and/or
distress
 The Question
• Are people with personality disorders
qualitatively different from people without?
OR
• Are personality disorders simply extreme
versions of otherwise normal personality
variations?
 The Answer
• Personality disorders are probably best
thought of as extremes on one or more
personality dimensions
 Prevalence

• 7 - 12% of the general population.

• highest for obsessive-compulsive personality
disorder (4.32%; 95% CI, 2.16-7.16%)
• lowest for dependent personality disorder
(0.78%; 95% CI, 0.37-1.32%).

Prevalence of personality disorders in the general

adult population in Western countries: systematic
review and meta-analysis
Jana Volkert , Thorsten-Christian Gablonski , Sven
Rabung
PMID: 30261937 DOI: 10.1192/bjp.2018.202
 Course
• Thought to originate in childhood and
continue into adulthood
• Believed to be relatively stable, difficult to
treat
 Comorbidity
• Considerable overlap among categories
• About 50% of people diagnosed with one personality
disorder also meet criteria for another
• Questions
– Do people really tend to have more than one personality
disorder?
– Do rates of comorbidity indicate problems with reliability
and validity of diagnostic categories?
 Three Clusters

• Cluster A: odd/eccentric

• Cluster B: dramatic/erratic

• Cluster C: anxious/fearful
 Cluster A: Odd or Eccentric
• Paranoid
• Schizoid
• Schizotypal
 Paranoid Personality Disorder

• pervasive pattern of distrust and

suspiciousness of others such that their
motives are interpreted as malevolent
 DSM5: at least 4 Sx
1. Suspects others are exploiting, harming, or
deceiving him
2. Preoccupied with doubts about
loyalty/trustworthiness of friends, associates
3. Reluctant to confide in others (fears info will be
used against him)
 DSM5 (continued)
4. Reads hidden threatening meanings into benign
events
5. Bears grudges, is unforgiving
6. Perceives attacks on character or reputation and is
quick to counterattack
7. Suspicious of fidelity of sexual partner
 Causes
• Biological
– slightly more common among relatives of people
with schizophrenia
• Psychological
– theory: certain basic mistaken assumptions about
others
– “people are malevolent and deceptive” and
“they will attack you if they get the chance”
– result of upbringing? taught by parents?
 Treatment
• Unlikely to seek professional help; difficulty
trusting therapist
• Difficulty that brings them in is a crisis
• Cognitive therapy
– Changing person’s mistaken beliefs about others
• No confirmed demonstrations that any form
of tx works
 Schizoid Personality Disorder
• Pervasive pattern of detachment from social
relationships and restricted range of
expression of emotion in interpersonal
settings.
 DSM5: at least 4 Sx
1. Neither desires nor enjoys close relationships
2. Chooses solitary activities
3. Little, if any, interest in sexual experiences with
another person
4. Lacks close friends
5. Appears indifferent to praise/criticism
6. Shows emotional coldness, detachment
7. Takes pleasure in few, if any, activities
 Causes and Treatment
• Causes
– No research
– Preference for social isolation resembles aspects of autism
• Treatment
– Don't usually seek tx (only in response to crisis)
– Point out value of social relationships
– Learn empathy
– Social skills training
– Many therapists believe therapy doesn't help this group
 Schizotypal Personality Disorder

• pervasive pattern of social and

interpersonal deficits marked by acute
discomfort with, and reduced capacity
for, close relationships and cognitive
or perceptual distortions and
eccentricities of behavior.
 DSM5: at least 5 Sx
1. Ideas of reference
2. Odd beliefs or magical thinking
3. Unusual perceptual experiences
4. Odd thinking and speech
5. Suspiciousness/paranoia
 DSM5 (continued)
6. Inappropriate or constricted affect
7. Behavior or appearance that is odd, eccentric, or
peculiar
8. Lack of close friends
9. Excessive social anxiety: associated with paranoid
fears
 Causes and Treatment
• Biological
– More common among relatives of people with
schizophrenia
• Treatment
– Research is limited
– Tx for comorbid depression
– Psychological: social skills to help reduce isolation or help
person adjust to solitary lifestyle
– Medical: Haloperidol. Results in improvement in some Sx,
but many stop taking it due to side effects
 Cluster B: Dramatic or Erratic
• Antisocial
• Borderline
• Histrionic
• Narcissistic
 Cluster B: Dramatic or Erratic
• Antisocial
• Borderline
• Histrionic
• Narcissistic
 Antisocial Personality Disorder

• Pervasive pattern of disregard for and

violation of the rights of others since age 15.
 Antisocial: DSM5
• At least 3 Sx
1. Failure to conform to social norms with respect to lawful
behavior (repeated arrests)
2. Deceitfulness (repeated lying, use of aliases, conning)
3. Impulsivity, failure to plan ahead
4. Irritability and aggressiveness (repeated fights)
5. Reckless disregard for safety of others
6. Consistent irresponsibility (no steady employment,
doesn’t honor financial obligations)
7. Lack of remorse (indifferent to or rationalizes having hurt,
mistreated, or stolen from others)
 Antisocial: DSM5 (continued)
• Must be at least 18
• Evidence of conduct disorder prior to age 15:
1. Violation of basic rights of others and major social rules
2. Aggression toward people and/or animals
3. Destruction of property
4. Deceitfulness or theft
5. Serious violation of rules (stays out all night, truant)
 Psychopath
• Antisocial personality disorder overlaps with
personality trait called“psychopath”
– Shallow or superficial charm
– Grandiose sense of self-worth
– Proneness to boredom/need for stimulation
– Pathological lying
– Conning/manipulative
– Lack of remorse
• Not all psychopaths display aggressiveness that is a
DSM criterion for antisocial personality.
 Causes: Biological
• Genetics
– Family, adoption, and twin studies show evidence
of a genetic link
– Examples:
• Offspring of felons raised by adoptive families show
higher rates of arrests and antisocial personality
disorder than controls
• Concordance rates for criminality are 55% for MZ twins
and 13% for DZ twins
 But what do they inherit?
• Underarousal hypothesis
– Psychopaths have abnormally low levels of cortical
arousal
– Engage in antisocial and risk-taking behaviors to
increase level of arousal
– Evidence
• Longitudinal study found that future criminals had
lower skin conductance activity, lower heart rate, and
more slow-frequency brain wave activity
 Causes: Biological
• Fearlessness hypothesis
– Psychopaths have a higher threshold for
experiencing fear than most people
– Evidence
• Psychopaths are less likely to develop a classically
conditioned fear response
 Psychological and Social Influences
• Oversensitivity to reward
– Will persist in efforts to achieve goal, even when goal is no
longer attainable
• Inconsistent parental discipline
– Giving in to problem behavior and poor monitoring
• Other environmental influences
– Low SES, stress, and degree of mutual trust and solidarity
in neighborhood linked to antisocial behaviors
 Antisocial: Treatment
• Prognosis for adults is poor
• Best strategy is to intervene with ‘’high risk’’
children
– Teach parents to use behavioral management
principles to reduce problem behavior and
increase prosocial behavior
– Research suggests such programs reduce
antisocial behavior

‫أي شخصية تتذكرونها؟‬

 Cluster B: Dramatic or Erratic
• Antisocial
• Borderline
• Histrionic
• Narcissistic
 Borderline Personality Disorder

• Pervasive pattern of instability of

interpersonal relationships, self-image, and
affect marked by impulsivity
 Borderline: DSM5: at least 5 Sx

1. Frantic efforts to avoid real or imagined

abandonment
2. Intense and unstable interpersonal relationships
– Alternate between extremes of idealization and
devaluation
3. Unstable self-image or sense of self
4. Impulsivity in at least 2 areas that are potentially
self-damaging (sex, money)
 Borderline: DSM5 (continued)
5. Recurrent suicidal behavior or self-mutilation
6. Emotional instability due to marked reactivity of
mood
7. Chronic feelings of emptiness
8. Inappropriate, intense anger
9. Transient, stress-related paranoid thoughts or
dissociative Sx
 Borderline: Causes
• Family studies
– Suggest genetic link
– Suggest that BPD is linked to mood disorders
• Early trauma
– 91% report h/o childhood sexual or physical abuse
• One theory
– Child who has biological vulnerability to emotional
dysregulation and is raised by invalidating family
 Borderline: Treatment
• Few controlled studies
• Medical
– Many respond positively to antidepressants and
Lithium (mood stabilizers).
 Borderline: Treatment (continued)
• Psychological
– Dialectical behavior therapy DBT
• Help people cope with stressors that trigger suicidal behaviors
• Teach patients how to identify and regulate their emotions
• Teach problem solving
• Re-exposure to prior traumatic events to extinguish fear
• Trust own responses, rather than depend on others for validation
– Reduces suicide attempts, dropouts from treatment, and
hospitalizations
 Cluster B: Dramatic or Erratic
• Antisocial
• Borderline
• Histrionic
• Narcissistic
 Histrionic Personality Disorder

• Pervasive pattern of excessive emotionality

and attention seeking
 Histrionic: DSM5: at least 5 sx

1. Uncomfortable when not the center of attention

2. Inappropriate sexually seductive or provocative
behavior
3. Rapidly shifting and shallow expression of emotions
4. Consistently uses physical appearance to draw
attention to self
 Histrionic: DSM5 (continued)
5. Speech is excessively impressionistic and lacking in
detail
6. Shows self-dramatization, theatricality, and
exaggerated expression of emotion
7. Highly suggestible
8. Considers relationships to be more intimate than
they actually are
 Histrionic: Causes and Treatment
• Very little research
• Try to teach more appropriate ways of
expressing their needs and getting their needs
met
– Point out costs associated with manipulative style
 Cluster B: Dramatic or Erratic
• Antisocial
• Borderline
• Histrionic
• Narcissistic
 Narcissistic Personality Disorder

• Pervasive pattern of grandiosity, need for

admiration, and lack of empathy
 Narcissistic: DSM5: at least 5 sx

1. Grandiose sense of self-importance

– Example: exaggerates achievements and talents
2. Preoccupied with fantasies of unlimited success,
power, beauty, etc.
3. Believes he/she is special and unique
– Can only be understood by or associate with other special
high status people
4. Requests excessive admiration
5. Sense of entitlement
– Unreasonable expectations for favorable treatment
 Narcissistic: DSM5 (continued)
5. Interpersonally abusive
6. Lacks empathy
7. Often envious of others, or believes others
are envious of him/her
8. Arrogant, superior behaviors or attitudes
 Narcissistic: Causes
• Little research
• One theory:
– Grandiosity is a defense against very fragile self-
esteem
– Develops because parents do not respond with
approval to child’s displays of competency

‫قال عمر بن الخطاب رضي هللا عنه‬:

“‫ اال لمهانة يجدها في نفسه‬،‫”ما وجد أحد في نفسه كبرا‬
video
 Narcissistic: Treatment
• Little research
• Therapy focuses on grandiosity, sensitivity to
evaluation, and lack of empathy
 Cluster C: Anxious or Fearful

• Avoidant
• Dependent
• Obsessive-compulsive
 Avoidant Personality Disorder
• Pervasive pattern of social inhibition, feelings
of inadequacy, and hypersensitivity to
negative evaluation
 DSM5: at least 4 Sx
1. Avoids occupational activities that involve
significant interpersonal contact, because of fears
of criticism, disapproval, or rejection
2. Unwilling to get involved with people unless certain
of being liked
3. Shows restraint in interpersonal relationships
because of fears of being shamed or ridiculed
 DSM5 (continued)
4. Preoccupied with being criticized or rejected in
social situations
5. Inhibited in new interpersonal situations
6. Views self as socially inept, unappealing, or inferior
7. Reluctant to take risks or engage in new activities
(due to fears of embarrassment)
 Causes
• One theory
– Person born with difficult temperament or
personality characteristics
– Parents reject them or don’t provide enough early,
uncritical love
– Rejection results in low self-esteem and social
alienation
 Treatment
• Controlled studies show evidence for
effectiveness of behavioral intervention
techniques for anxiety and social skills
– Systematic desensitization
– Behavioral rehearsal
 Dependent Personality Disorder

• Pervasive and excessive need to be taken care

of that leads to submissive, clinging behavior
and fears of separation
 DSM5: at least 5 Sx
1. Difficulty making everyday decisions
2. Needs others to assume responsibility
3. Difficulty expressing disagreement
– Due to fears of loss or support or approval
4. Difficulty initiating projects or doing things
on his/her own
– Due to lack of self-confidence in own judgment or
abilities
 DSM5 (continued)
5. Goes to excessive lengths to obtain nurturance and
support
– Volunteers to do unpleasant things
6. Feels uncomfortable or helpless when alone
– Because of fears of being unable to take care of self
7. Urgently seeks another relationship as a source of
care/support when one ends
8. Preoccupied with fears of being left to take care of
him/herself
 Causes and Treatment
• causes
– one theory is that early death of parent or
neglect/rejection by caregiver cause person to
grow up fearing abandonment
• treatment
– little research
– Assertiveness training.
 Obsessive-Compulsive Personality
Disorder
• Pervasive pattern of preoccupation with
orderliness, perfectionism, and mental and
interpersonal control, at the expense of
flexibility, openness, and efficiency
 DSM5: at least 4 sx
1. Preoccupied with details, rules, lists, order,
organization, or schedules to the extent that the
major point of the activity is lost
2. Perfectionism that interferes with task completion
3. Excessively devoted to work and productivity to the
exclusion of leisure activities and friendships
4. Overconscientious and inflexible about morality,
ethics, or values
 DSM5: at least 4 sx
5. Unable to discard worn-out or worthless objects
– Even when they have no sentimental value
6. Reluctant to delegate tasks
– Unless others submit to person’s exact way of doing
things
7. Has stingy spending attitude
– Money to be hoarded for future catastrophes
8. Rigidity and stubbornness
 Causes and Treatment
• Causes
– Weak genetic contribution
– Possible parental reinforcement of conformity and
neatness
• Treatment
– Little research
– Therapy addresses fears that underlie need for orderliness
– Relaxation techniques
THANK YOU